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Interval House, Mercy House, and Families Forward - 2018-10-01
City of Huntington Beach 19PPP,_0VEb 7-0 File #: 18-336 MEETING DATE: 10/1/2018 REQUEST FOR CITY COUNCIL ACTION SUBMITTED TO: Honorable Mayor and City Council Members SUBMITTED BY: Fred A. Wilson, City Manager PREPARED BY: Kellee Fritzal, Deputy Director of Economic Development Subject: Approval and authorization of the implementation of three (3) Tenant Based Rental Assistance (TBRA) Program Agreements between the City and Interval House, Mercy House, and Families Forward; and, approve increased budget appropriation Statement of Issue: The City Council is asked to approve three (3), 21-month Agreements between the City and Interval House, Mercy House and Families Forward for the implementation of the Tenant -Based Rental Assistance (TBRA) Program. The agreements will serve extremely low, very low and low income households. The total of three agreements will be funded by Federal HOME Investment Partnership Funds and by the City's Affordable Housing In -Lieu Fee Fund. In addition, an increase of $257,350 in appropriations for Affordable Housing In -Lieu Funds is requested to expend prior years' fund balance. Financial Impact: There are sufficient fund balances in the Affordable Housing In -Lieu Fee Fund (217) and grant revenues totaling $535,978 in the HOME Investment Partnership Funds (1209, 1220 and 240) to implement the first year commitment of the agreements. The second year of funding will be allocated in the FY 2019/20 budget. The Projects require additional appropriation of $257,350 from the City's Affordable Housing In -Lieu Fee Fund (Fund 217). Recommended Action: A) Approve and authorize the City Manager and City Clerk to execute a two-year "HOME Recipient Agreement Between the City of Huntington Beach and Interval House" for the implementation of a Tenant -Based Rental Assistance (TBRA) program; and, B) Approve and authorize the City Manager and City Clerk to execute a two-year "HOME Recipient Agreement Between the City of Huntington Beach and Mercy House" for the implementation of a Tenant -Based Rental Assistance (TBRA) program; and, City of Huntington Beach Page 1 of 4 Printed on 9/26/2018 396 powered by Legistar`l File #: 18-336 MEETING DATE: 10/1/2018 C) Approve and authorize the City Manager and City Clerk to execute a two-year "HOME Recipient Agreement Between the City of Huntington Beach and Families Forward" for the implementation of a Tenant -Based Rental Assistance (TBRA) program; and, D) Authorize the City Manager to sign all necessary documents to effectuate the Agreement with Interval House, Mercy House and Families Forward, any future minor amendments to contracts, and/or US Department of Housing and Urban Development (HUD) documents, as approved as to form by the City Attorney; and, E) Approve an increased budget appropriation for the Affordable Housing In -Lieu Fee Fund in the amount of $257,350 (Fund 217). Alternative Action(s): Do not approve programs and direct staff as necessary. Analysis: Annually, the City is allocated HOME funds from the U.S. Department of Housing and Urban Development (HUD). A TBRA program is eligible under HOME guidelines to allocate funds to provide a rental subsidy to individual households to afford housing costs such as rental assistance, security and utility deposits. TBRA sub -recipients listed below will work with the City's Homeless Task Force and Police Department targeting homeless veterans, seniors, at -risk families, and individuals with demonstrable ties to the City of Huntington Beach. The goal is to meet their immediate needs and create pathways which will allow them to quickly move into stable, self-sufficient, permanent housing. Funding will be used to provide short -to -medium -term rental assistance to households that are currently homeless or those who have exhausted other options and are at risk of becoming homeless without such funding. In addition to rental assistance, the non -profits provide case management/client services, household inspections and other services to assist the clients to become self-sufficient. The number of clients served can increase, based upon services provided, length of service and case management. On average, a client, including rental assistance, case management and all related services costs averages approximately $700 to $970 a month. Each client household pays a portion of the rent, which is increased towards full rental self-sufficiency. Interval House The City implemented its first Tenant Based Rental Assistance Program (TBRA) in 2015 with Interval House. Interval House successfully housed 42 households (92 people) from October 2015 - September 2017. On August 21, 2017, the City Council approved an amendment with Interval House for a third year which was implemented October 1, 2017 - September 30, 2018. During their one- year contract, Interval House housed an additional 14 households (20 people). Interval House has successfully housed 56 households in the last 3 years. Interval House provided assistance to referrals made by the Huntington Beach Homeless Task Force, including the City's homeless, veterans, seniors, and domestic violence victims. The proposed 21-month agreement (October 1, 2018 - June 30, 2020) with Interval House will City of Huntington Beach Page 2 of 4 Printed on 9/26/2018 397 powered by LegistarTI File #: 18-336 MEETING DATE: 10/1/2018 provide financial assistance to 22 eligible extremely low, very low and low income families and households. Forty percent (40%) of referrals will be made from the Homeless Task Force, Huntington Beach Police Department (HBPD), and Interval House. The amount of HOME funds to be paid under the agreement total $374,156 and $74,000 from Affordable Housing In -Lieu Funds, totaling $448,156. Mercy House In 2016, the City implemented a TBRA program with Mercy House from October 1, 2016 - September 30, 2018. To date, Mercy House has housed 32 households (82 people). Mercy House provided housing to households referred primarily through the Homeless Task Force and HBPD. The proposed 21-month agreement with Mercy House will provide assistance to 34 extremely low, very low and low income households. Seventy-five percent (75%) of new clients will be referred by the HBPD and the Homeless Task Force. Mercy House's TBRA program will assist Huntington Beach households who are homeless or at imminent risk of homelessness with preference given to veterans and seniors. The amount of HOME funds to be paid under the agreement total $401,400 and $92,000 from Affordable Housing In -Lieu Funds, totaling $493,400. Families Forward The TBRA Agreement with Families Forward is a new partnership between the City and this non- profit. The Families Forward 21-month TBRA agreement will provide assistance to 30 homeless and nearly homeless households who plan to transition into permanent housing. The City requests that fifty percent (50%) of the new clients be referred by HBPD and the Homeless Task Force. Huntington Beach families that are homeless can be referred into the TBRA through the Orange County Coordinated Entry System. The amount of HOME funds to be paid under the agreement is $521,500 and $91,350 from Affordable Housing In -Lieu Funds, totaling $612,850. All TBRA sub -recipients will work with the City's Homeless Task Force and Police Department targeting homeless veterans, seniors, and at -risk families and individuals with demonstrable ties to the City of Huntington Beach. The goal is to meet their immediate needs and create pathways which will allow them to quickly move into stable, self-sufficient, and permanent housing. Funding will be used to provide short -to -medium -term rental assistance to households that are currently homeless or those who have exhausted other options and would become homeless without funding. Staff recommends approving and entering into the agreements with Interval House, Mercy House and Families Forward as sub -recipients of HOME funds to implement the City's TBRA program. Overall, over the 21-month period, a total of 86 homeless or at -risk households will be served through these agreements. Environmental Status: A level of Environmental Review was completed and the program is Categorically Excluded, Not Subject to 58.5 per 24 CFR 58334(a) and 58.35(b) Tenant -Based Rental Assistance (U.S. Department of Housing and Urban Development). City of Huntington Beach Page 3 of 4 Printed on 9/26/2018 398 powered by Legistar," File #: 18-336 MEETING DATE: 10/1/2018 Strategic Plan Goal: Improve quality of life Attachment(s): 1. HOME Recipient Agreement between the City of Huntington Beach and Interval House (Tenant -Based Rental Assistance) 2. HOME Recipient Agreement between the City of Huntington Beach and Mercy House (Tenant - Based Rental Assistance) 3. HOME Recipient Agreement between the City of Huntington Beach and Families Forward (Tenant -Based Rental Assistance) City of Huntington Beach Page 4 of 4 399 Printed on 9/26/2018 powered by Legistar " ATTACHMENT #1 City of Huntington Beach 2000 Main Street ® Huntington Beach, CA 92648 (714) 536-5227 ♦ www.huntingtonbeachca.gov Office of the City Clerk - Robin Estanislau, City Clerk October 8, 2018 Interval House Attn: Carol Williams 6615 E. Pacific Coast Highway, Suite 170 Long Beach, CA 90803 Dear Ms. Williams: Enclosed is a copy of the fully executed "Home Recipient Agreement between the City of Huntington Beach and Interval House." Sincerely, Robin Estanislau, CIVIC City Clerk RE:ds Enclosure Sister Cities. Anjo, Japan ♦ Waitakere, New Zealand HOME RECIPIENT AGREEMENT BETWEEN THE CITY OF HUNTINGTON BEACH AND INTERVAL HOUSE (Tenant Based Rental Assistance) This HOME RECIPIENT AGREEMENT (Tenant Based Rental Assistance) ("Agreement") is made and entered into as of (, -hXr II &L$ (`Effective Date") by and between the CITY OF HUNTINGTON BEACH, a municipal corporation and charter city ("City"), and INTERVAL HOUSE, a California nonprofit public benefit corporation ("Subrecipient"). RECITALS A. City is a California municipal corporation and charter city under the laws of the State of California. B. City has applied for and received funds ("HOME Funds") from the United States Department of Housing and Urban Development ("HUD") pursuant to the HOME Investment Partnerships Act and HOME Investment Partnerships Program, 42 U.S.C. §12701, et seq., and the implementing regulations set forth in 24 CFR § 92.1, et seq. (together, "HOME Program") for the purposes of strengthening public -private partnerships to provide more affordable housing, and particularly to provide decent, safe, sanitary, and affordable housing for very low income and lower income citizens of Huntington Beach in accordance with the HOME Program. As used herein, the HOME Program includes the HUD Final Rule set forth at 78 FR 142, adopted July 24, 2013, which adopts substantial amendments to the HOME Program regulations set forth at 24 CFR Part 92. C. City is currently implementing a coordinated 21 month strategy and program to provide financial assistance to eligible extremely low, very low and lower income families and households to enable such households to secure housing available at an affordable housing cost in the City. D. City has developed a Tenant Based Rental Assistance Program to assist veteran and senior families _ in the City to transition into permanent, supportive housing. Forty percent (40%) of new clients referred will be from the Huntington Beach Homeless Task Force. E. City wishes to engage the Subrecipient to assist the City in utilizing HOME Funds to provide tenant based rental assistance, security deposit assistance and utility assistance to veteran and senior residents of the City, in accordance with the terms and provisions set forth in this Agreement. 18-6743/185590/NW 1 NOW, THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows: ARTICLE 1 SCOPE OF SERVICES 1.1 Scope of Services. During the entire Term (defined below) of this Agreement, Subrecipient shall administer the City's HOME -funded Tenant Based Rental Assistance Program ("TBRA Program"), all in accordance with this Article 1 (collectively, the "Services") and the TBRA Program Operating Guidelines attached hereto as Exhibit A. In connection with the Services, Subrecipient shall comply with all requirements of the HOME Program, this Agreement and all applicable federal, state and local laws and regulations. Subrecipient shall further take all reasonable actions necessary to enable City to comply with City's obligations under the HOME Program relating to the TBRA Program. The Subrecipient shall perform the Services set forth in this Article I in furtherance of the TBRA Program. 1.2 Marketing and Outreach; Application Process. (a) Marketing and Outreach. Subrecipient shall undertake affirmative marketing and outreach activities to find prospective Eligible Households interested in the TBRA Program, all in accordance with HUD's Affirmative Fair Housing and Marketing regulations and the City's Affirmative Fair Housing Marketing Plan, when adopted. Subrecipient shall describe its marketing and outreach efforts in quarterly progress reports submitted to the City under this Agreement, as described in Exhibit B. (b) Waiting List. Subrecipient shall maintain a waiting list of prospective Eligible Households. The waiting list shall be prioritized first based on the most urgent need as determined by the Client Outcome Matrix Form set forth in Appendix I to the TBRA Program Operating Guidelines, prospective Eligible Households of equally urgent need will be helped on a first come -first served basis, based on the date and time of referral or initial direct contact with the Subrecipient. (c) Intake Process. Upon being contacted by a prospective Eligible Household (recruited through Subrecipent's affirmative marketing and outreach efforts), Subrecipient shall initially meet with such prospective Eligible Household to fill out an Initial Qualification Document in substantially the form attached as Appendix A to the TBRA Program Operating Guidelines, including an income calculation based on three months of source documentation (bank account statements, pay stubs, etc.) to prequalify such prospective Eligible Household. Subrecipient shall then meet with prequalified Eligible Households to determine and verify their qualifications and eligibility for assistance under the TBRA Program, provide such prequalified Eligible Households with the TBRA Program application and other documentation described below, assist prospective Eligible Households with the completion of the application and gross income calculation worksheet and qualify Eligible Households for the TBRA Program. Subrecipient 18-6743/185590/MV 2 shall provide every prequalified Eligible Household with all of the following documentation. (i) Forty percent (40%) of new clients will be referred by the Huntington Beach Homeless Task Force, The Deputy Director has the authority to waive the requirements. (ii) TBRA Application in the form attached to the TBRA Program Operating Guidelines as Appendix B, or as otherwise approved in writing by the Executive Director of Community Development (or his designee) on behalf of the City ("Deputy Director"). The TBRA Application shall solicit information regarding each applicant household's income and assets, household size and composition (number of children and adults), names of household members, Housing Unit (defined below) size and location preferences, specific needs and considerations, and a race/ethnicity survey. Examples of acceptable documental to confirm recent residency include: - Copy of previous lease - Copy of previous utility bill - Written confirmation of residency from a previous landlord, or proof of residency in transitional living facility - Copy of school records confirming previous residency Examples of proof of strong ties to the community include: - Current residency of an immediate family member — mother, father, sibling, child, or grandparent - Proof that the individual and/or their dependent(s) attended K-12 school in Huntington Beach - Written acknowledgement from the Huntington Beach Police Department or Homeless Task Force that individual has been living in Huntington Beach's streets for 18 months. Special Circumstances — the following categories of individuals may meet the definition of Huntington Beach Homeless Resident: - Homeless individuals that are "Medically Compromised" - Elderly homeless individuals (60+) - If the Huntington Beach Police Department (HBPD) or Homeless Task Force (HTF) staff believe that an individual's well-being will be severely compromised by living on the street and/or if the individual is a chronic nuisance or offender who's presence in Huntington Beach poses a threat to others or in a consistent drain on public resources, then a team composted of HBPD/HTF may, on a case -by -case basis, determine that such individual qualifies as a HB Homeless Resident. 18-67431185590/MV (iii) Declaration of Homelessness Status or Declaration of At -Risk of Homelessness Status, as appropriate, in the forms attached to the TBRA Program Operating Guidelines as Appendix C. (iv) Rental Assistance Contracts for the landlord and the Eligible Households, in the forms attached to the TBRA Program Operating Guidelines. Income Calculation Form in the form attached to this Agreement as Exhibit C. (v) Household Budget Worksheet in the form attached to this Agreement as Exhibit D. (vi) Lead -Based Hazard Information Pamphlet "Protect Your Family from Lead in Your Home" attached to this Agreement as Exhibit E. (d) Guidance for Eligible Households. Subrecipient shall meet with prospective Eligible Households throughout the application process and shall continue to meet with and counsel each Eligible Household regarding the TBRA Program, the Eligible Household's responsibilities as participants of the TBRA Program, and the goals and objectives of the TBRA Program. 1.3 Determination of Eligibility. Subrecipient shall qualify all Eligible Households in accordance with the selection criteria described in this Section. Further, for all Eligible Households Subrecipient shall implement the selection criteria and policies in compliance with the City's Consolidated Plan and the City's housing needs and priorities. (a) Eligible Household. As used in this Agreement, "Eligible Household" refers to extremely low income households that are (i) currently residents of the City of Huntington Beach, and (i) currently homeless or at risk of homelessness and (Ili) include at least one child (under the age of 19) enrolled and attending school in the City of Huntington Beach for at least 90 days prior to the time of admission into the TBRA Program. It is anticipated that the Eligible Households assisted pursuant to the TBRA Program will be the same households assisted pursuant to the ESG Agreement. (ii) For purposes of determining eligibility for the TBRA Program, a prospective Eligible Household's (or for continuing compliance, a participating Eligible Household's) gross annual income shall be determined in accordance with 24 CFR 5.609, with the allowable exclusions from income established at 24 CFR 5.611. For purposes of this Agreement, annual income means the gross amount of income from all sources, including assets, for all adult household members that is anticipated to be received prospectively during the 12-month period following the date of application and before any deductions are taken (and for a participating household, income anticipated for the 12 months following verification described in § 1.3(b)(ii) below.) When collecting 18-6743/185590/MV 4 income verification documentation, Subrecipient may also consider any likely changes in income. (iii) For purposes of this Agreement and the TBRA Program, income limits for extremely -low, very -low and low income households are established annually by HUD for the Orange County income limit area. (b) Income Verification. (i) Initial Verification. To determine if TBRA Program applicants (collectively, "Applicants") are income -eligible, Subrecipient must verify each Applicant's household income using source documentation such as wage statements, interest statements, unemployment compensation statements, and bank account statements, and other documentation types approved by HUD. Once an initial income verification is completed, the Subrecipient is not required to re-examine the Eligible Household's income unless six months has elapsed before assistance is provided. (ii) Annual Eligibility Verification. Subrecipient shall annually re -certify income and re -qualify each Eligible Household, including examination of source assistance must be terminated following a 30 day notification period. For households between 60% and 80% AMI the Subrecipient must obtain approval from the City before rental assistance is continued. (c) Verification of Eligibility. Subrecipient shall collect and examine source documentation submitted by the Applicant to verify the identity of the members of the Eligible Household and that the Eligible Household includes at least one child (under 19 years old) attending school in the City (and enrolled in a school in the City as of January 1, 2018). Subrecipient shall make a determination that the Eligible Household is currently experiencing homelessness or is at risk of homelessness, as defined in the ESG Program (24 CFR 576.2), based on caseworker observations and certification and Applicant certification. (d) Written Notice of Eligibility Determination. Subrecipent shall provide written notice to each Applicant stating whether such Applicant was determined to be eligible for assistance under the TBRA Program. Applicants determined to be ineligible for TBRA Program assistance shall have an opportunity to appeal the determination to the Subrecipient's Executive Director. If the issue is not resolved, the case will be referred to the Deputy Director. The definitions of "homelessness" and "at risk of homelessness" under the ESG Program (24 CFR 576.2) are applicable to this Agreement. 1.4 Selection of Housing Units. (a) Housing Unit Selection. Subrecipient shall assist Eligible Households with finding and selecting an appropriate housing unit (each a "Housing l 8-6743/l 85590/MV 5 Unit") that meets federal housing quality standards ("HQS") or such other standards as may be made applicable to the TBRA Program by HOME Program statutes and/or regulations, specifically including Uniform Physical Condition Standards (UPCS), and that satisfies the requirements of the TBRA Program, HOME Program and this Agreement. Eligible Households shall also be entitled to find a Housing Unit for themselves, subject to compliance with the requirements of the TBRA Program, HOME Program and this Agreement; however, the parties anticipate that in most cases, Subrecipient shall be responsible for locating and qualifying an appropriate Housing Unit for occupancy by each Eligible Household. Subrecipient may refer Eligible Households to appropriate Housing Units but may not require an Eligible Household to select a particular Housing Unit. Subsidy Payments shall only be provided in connection with the rental of a qualified Housing Unit located in the City, unless Subrecipient documents reason for selecting housing outside the City. Subsidy Payments under this Agreement are portable within the City. Subsidy payments under this Agreement are portable within the City. Subrecipient's obligations under this Section 1.4 apply to each Housing Unit to be occupied by an Eligible Household receiving Subsidy Payments hereunder. (b) Housing Unit Size; Occupancy Standards. Housing unit selection shall comply with the following "Occupancy Standards" for the applicable Eligible Household: No more than two persons per bedroom plus one may occupy the Housing Unit. Thus, no more than three persons may occupy a one -bedroom Housing Unit, no more than five persons may occupy a two bedroom Housing Unit; no more than seven persons may occupy a three bedroom Housing Unit; no more than nine persons may occupy a four bedroom Housing Unit. (c) Property Inspection. Prior to occupancy of any Housing Unit by an Eligible Household, and again during the annual (or more often) verification process, Subrecipient shall cause a certified HQS inspector to inspect each Housing Unit occupied or to be occupied by an Eligible Household to ensure the Housing Unit complies with HQS as set forth in the HOME Program, including without limitation 24 CFR 92.251, as well as all applicable state and local codes and ordinances, including zoning ordinances. Subrecipient shall provide the City with documentation of each HQS inspector's certification. Each HQS inspection shall include all of the following: (i) Verification of the age of the Housing Unit; (ii) Complete HQS Inspection Checklist in the form attached as Exhibit G, including a rating for the Housing Unit of Pass, Pass with Comment, or Fail; 18-6743/185590/MV 6 (iii) Lead -based hazard assessment, dissemination of lead -based hazard information pamphlet and disclosure form and lead -based hazard reduction activities, if required by the HOME Program or applicable federal, state and/or local laws; (iv) Adequate opportunity for the Landlord (defined below) to correct any deficiencies indicated in the HQS Inspection Form to bring the Housing Unit into compliance with HQS requirements; (v) Verification that occupancy by the Eligible Household will comply with the Occupancy Standards set forth in Section 1.4(b); and (vi) Certification of rent reasonableness regarding the rent being charged for the Housing Unit based on comparable non -assisted Housing Units in the same area. Subrecipient shall perform the rent reasonableness review subject in each instance to review and approval by the City. City may elect to perform the rent reasonableness reviews on behalf of Subrecipient by providing written notice to Subrecipient. The rent charged under the written lease agreement for the Housing Unit shall conform to the rent reasonableness standard pursuant to the TBRA Program Operating Guidelines, which is based on local market conditions. The contract rent for Housing Units that are restricted to an affordable rent by agreement with the City or by regulation or ordinance, or otherwise, shall be likewise restricted to such affordable rent in accordance with the contractual, statutory or regulatory restrictions governing the permitted rents for such Housing Units and the Rental Assistance Subsidy Payment shall be limited and calculated accordingly, as described in Section 1.5(a), below. (d) Coordination with Landlords. (i) Landlord Guidance. Subrecipient shall provide guidance to the property owners, property owners' representatives, or property management companies hired by property owners (each a "Landlord" and collectively referred to as "Landlords") participating in the TBRA Program regarding the TBRA Program requirements and procedures that impact Landlords. (ii) Landlord Agreement. Subrecipient shall enter into a Landlord Agreement with each participating property owner/Landlord in substantially the form attached to the TBRA Program Operating Guidelines as Appendix E. The Landlord Agreement will establish the Subsidy Payments to be made by Subrecipient on behalf of the Eligible Household as well as the Eligible Household's initial share of the contract rent. The Landlord Agreement shall further establish the terms and conditions under which the Subsidy Payments shall be paid to the Landlord for the applicable Housing Unit, l 8-6743/185590/MV 7 including applicable HOME Program requirements. The Landlord Agreement shall have an initial term of 6-12 months, subject to extensions approved by Subrecipient and City (as applicable) pursuant to the TBRA Program Operating Guidelines. (iii) Tenant Protection Agreement. Subrecipient shall require each Landlord to enter into a lease agreement with a term of 12 months with any Eligible Household occupying a Housing Unit owned and/or managed by such Landlord, which lease agreement shall include a Tenant Protection Agreement in substantially the form attached to the TBRA Program Operating Guidelines as Appendix F, or an updated form of Tenant Protection Agreement as may be prepared and provided by the City to the Subrecipient, and then by Subrecipent to Landlord. The Tenant Protection Agreement shall be executed in connection with the lease agreement between the Landlord and Eligible Household. The Tenant Protection Agreement will prohibit the inclusion of prohibited lease terms listed at 24 CFR 92.253; confirm the Landlord's obligation to maintain the Housing Unit in accordance with HQS, as established at 24 CFR 982.401; and prohibit discrimination by the Landlord against the Eligible Household. Interval House will review the lease agreement to confirm its compliance with state law and all HOME Program requirements. If the Landlord's form of rental agreement is not acceptable, Subrecipient shall require the Landlord and Eligible Household to enter into a lease agreement that complies with state law, HOME requirements, and City requirements. 1.5 Subsidy Payments. Subrecipient shall make rent payments, security deposit payments and/or utility deposit payments, as applicable (collectively, the "Subsidy Payments"), to Landlords and/or to utility providers, as applicable, on behalf of Eligible Households. Subsidy payments must be provided in accordance to the Subrecipient's TBRA Program Operating Guidelines. Eligible Households are not expected to repay Subsidy Payments received pursuant to the TBRA Program. Except as may be permitted by the HOME Program, Subrecipient's sole remedy in the event of noncompliance or breach by an Eligible Household shall be non -renewal of assistance under the TBRA Program. (a) Rental Assistance Calculation. Subrecipient shall calculate the "Rental Assistance" payments to be paid on behalf of each Eligible Household under this Agreement. The initial household rent is equivalent to the maximum subsidy amount allowed under the HOME regulations- and is calculated as the difference between 30% of the Eligible Household's gross monthly income and the payment standard for the size of the unit. (b) Payment Standards. Subrecipient must use the City's current payment standards as set forth in the Rent Reasonable Standards attached to the TBRA Program Operating Guidelines as Appendix G. The Housing Authority's payment standards represent the cost of rent and utilities for moderately priced units in Huntington Beach. Payment standards are established by bedroom size. 18-6743/185590/MV 8 (c) Utility Allowance. When utilities are included in the cost of renting a unit, that is, the owner assumes responsibility for payment for all utility services, the Eligible Households entire share of the housing costs will go directly to the owner. When the cost of utilities is not part of the rent, that is, the Eligible Household is directly responsible for payment of utility services, the Eligible Household's initial share will be determined by subtracting a utility allowance from 30% of the Eligible Household's gross monthly income. The Subrecipient must use the County of Orange's Housing Authority's Utility Allowance Schedule attached to the TBRA Program Operating Guidelines as Appendix H. (d) Term, 12. The Subrecipient will provide rental assistance for an initial term of 6- 12 months, which can be extended in 6-12 month intervals, up to a total of six times, for a cumulative term of up to 24 months. Extensions will be granted at the discretion of the Subrecipient and shall be based on continued program compliance and ongoing need. The Subrecipient will evaluate ongoing need. (e) Security Deposit Assistance. Subrecipient may provide security deposit assistance to each Eligible Household. It is anticipated that Subrecipient shall provide Security Deposit Assistance to each Eligible Household in an amount of up to the lesser of: (A) two months' non -subsidized tenants. The lease agreement must provide that the security deposit is refundable in accordance with state law. Security deposit refunds shall be provided by the Landlord directly to the Eligible Household. Any disputes involving the return, or lack thereof, of a security deposit shall be settled by Eligible Household and landlord, as provided for in the lease. (f) Utility Deposit Assistance. Subrecipient may provide utility deposit assistance on behalf of each Eligible Household. It is anticipated that the Subrecipient will provide utility deposit assistance to each Eligible Household in the full amount of any utility deposit required for electricity, gas, and/or water service to the utility provider when needed to assist the Eligible Household in establishing tenancy. Utility deposit assistance may be provided only if the following requirements are met: (1) Utility deposit assistance is only available where rental assistance and/or security deposit assistance are also being provided. (ii) Utility deposit assistance shall be paid directly to the Landlord or utility provider, as applicable, on behalf of the Eligible Household. Utility deposit refunds shall be returned directly to the Eligible Household. 1.6 Administrative Cost Reimbursements. The City will reimburse the Subrecipient for allowable costs incurred in administering the TBRA Program, which are associated with the determination of income eligibility, pursuant to 24 CFR 92.203, and property 18-6743/185590/MV 9 inspections under HQS, codified per 24 CFR 982.401. Administrative costs incurred in administering the TBRA Program that are ineligible under the HOME Program will be reimbursed from a non -HOME Program funding source, or Inclusionary Funds. The administrative costs to be reimbursed from the Inclusionary Funds include Intake Assessments, Housing Search, Case Management, Self -Sufficiency and related services and overhead. 1.7 Termination of Assistance and Returning Eligible Households. (a) Termination of Rental Assistance. Subrecipient may terminate assistance under the TBRA Program for any of the following reasons: (1) Eligible Household is evicted from the Housing Unit based on behavioral issues or unlawful activity; (ii) Eligible Household has violated TBRA Participant Program; (iii) Eligible Household will be assisted by another rental assistance program such as the Section 8 Tenant -Based or Project -Based Programs. Participation in any other rental assistance program is considered a duplicative subsidy therefore all HOME funded rental assistance must be terminated. 1.8 Returning Eligible Households. As needed, Eligible Households may be allowed to return to the program for rental assistance. A determination to allow re-entry shall be based on the following criteria: (i) Eligible Households must have left the program in good standing. To be in good standing, Eligible Households must have been engaged in their case management plan, voluntarily left the program (not in lieu of termination) or have been released because their household income exceeded eligibility limits. In general, Eligible Households will not be allowed to re-enter the program if they were terminated for non-compliance. (ii) At the discretion of the Subrecipient, a request for re -admission from a prospective Eligible Household previously terminated due to non- compliance may be considered when compelling reasons exist. In such cases, re -admission will require concurrence from the City. (iii) Eligible Households may return so long as the previous rental assistance did not exceed 24 months. Cumulatively, Eligible Households may not receive rental advice for more than a cumulative period of 24 months unless such assistance is permitted by the HOME Program and approved by the City. 18-6743/185590/MV 10 1.8 Additional Requirements. (a) Self -Sufficiency Program. Subrecipient shall require each Eligible Household receiving Subsidy Payments from the Subrecipient to participate in a "Self - Sufficiency Program" administered by Subrecipient in accordance with the ESG Agreement and the Case Management and Self Sufficiency Program Policies and Procedures attached to the TBRA Program Operating Guidelines as Appendix J. Failure of an Eligible Household that is already receiving Subsidy Payments to participate in the Self -Sufficiency Program shall not be grounds for termination of the Subsidy Payments, but may be grounds for non -renewal of Subsidy Payments upon expiration of the subsidy term. (b) No Fees. Subrecipient may not charge fees to any Eligible Household for the Services, Subsidy Payments, Self -Sufficiency Program or other services or assistance to be provided to Eligible Households under this Agreement. 1.9 Schedule of Performance. Subrecipient shall use its best efforts to perform the Services in accordance with the following schedule: (a) Affinnative marketing and outreach activities required by this Agreement shall commence immediately upon execution of this Agreement. (b) Subrecipient shall qualify Eligible Households, conduct HQS inspections, approve Housing Units, and move Eligible Households into approved Housing Units in accordance with the following milestone schedule: (i) Subrecipient shall process intake paperwork for and verify eligibility for TBRA Program assistance ("Enroll") for not fewer than forty (40) Eligible Households within three (3) months following execution of this Agreement. As program income becomes available and/or additional HOME Funds are contributed to the TBRA Program, Subrecipient shall use diligent efforts to enroll additional eligible households within not more than three (3) months following written notice from the City that such additional funds are expected to become available. (ii) Subrecipient shall assist each Enrolled Eligible Household in finding an appropriate Housing Unit and shall conduct an HQS inspection of such Housing Unit, all within two (2) months following Enrollment of such Eligible Household. (iii) Subrecipient shall commence providing Subsidiary Payments on behalf of each Eligible Household and shall assist each Eligible Household to move into an HQS-inspected and approved Housing Unit, all within three (3) months following Enrollment of such Eligible Household. 18-6743/185590/MV 11 (c) Subrecipient shall cause each Eligible Household to commence participation in the required self-sufficiency program immediately upon Enrollment of such Eligible Household, whether or not such Eligible Household has yet moved into a Housing Unit and received the benefit of Subsidy Payments hereunder. 1.10 City Oversight and Approval Rights. City shall have the right, by written notice to Subrecipient at any time during the Term of this Agreement, to require City review and/or pre -approval of any of the Services to be performed by Subrecipient hereunder, including for example income determinations, qualification of applicants as "Eligible Households," qualification of Housing Units, determination of reasonable rents, etc., to ensure compliance with the TBRA Program, the HOME Program, or other applicable requirements. ARTICLE 2 TERM 2.1 Term. Services of the Subrecipient under this Agreement shall start on 10/1/18 and end on the earlier to occur of (i) 6/30/20 or (ii) the date the full amount of HOME Funds available under Section 3.2(a) below has been disbursed to Subrecipient and expended by Subrecipient to provide Subsidy Payments pursuant to this Agreement ("Term"), unless this Agreement is earlier terminated pursuant to Section 8.3. The Term of this Agreement and the provisions herein shall be further extended to cover any additional time period during which the Subrecipient remains in control of HOME Funds or other HOME assets, including program income. ARTICLE 3 BUDGET AND PAYMENTS 3.1 Budget. Subrecipient has submitted a budget to City for approval ("Budget"), which sets forth the estimated timing and use of the HOME Funds contributed by the City pursuant to this Agreement. The Budget is attached hereto as Exhibit F. Any amendments to an approved Budget for the Services must be approved by the City's Deputy Director or his or her authorized designee. In the event this Agreement is extended past the initial Term or any additional moneys will be contributed to the TBRA Program by City pursuant to this Agreement, Subrecipient shall prepare and submit to the Deputy Director for approval an updated Budget for such additional moneys. Subrecipient shall prepare a Budget, for approval by Deputy Director, for each year during which this Agreement remains in effect. The City may require a more detailed line item breakdown of the Budget than the one contained herein, and the Subrecipient shall provide such supplementary information about the Budget in a timely fashion in the form and content prescribed by the City. 3.2 Reimbursement of Subsidy Payments. City shall reimburse Subrecipient for Subsidy Payment actually disbursed to or on behalf of Eligible Households pursuant to this Agreement and in accordance with line items on the approved Budget or as otherwise approved by the City's Deputy Director. City shall have no obligation to reimburse Subrecipient for ineligible administrative costs or expenses incurred by Subrecipient to 18-6743/185590/MV 12 manage or implement the TBRA Program or this Agreement, for the cost of social or supportive services provided to Eligible Households hereunder, or for any other costs or expenses incurred by Subrecipient in connection with its activities under this Agreement. City's payment obligations hereunder shall be limited to the actual amount of Subsidy Payments disbursed by Subrecipient and eligible administrative costs in accordance with the terms of this Agreement and the approved Budget. Payments may be contingent upon certification of the Subrecipient's financial management system in accordance with the standards specified in 24 CFR 84.21. (a) Amount of Payments. It is expressly agreed and understood that the total amount of Home Program Funds to be paid by the City under this Agreement shall not exceed Three Hundred Seventy Four Thousand One Hundred Fifty -Six Dollars ($374,156). The amount of Inclusionary Funds to be paid by the City under this Agreement shall not exceed Seventy -Four Thousand Dollars ($74,000) annually. The dollar amount stated in the immediately preceding sentence may be increased by written amendment of this Agreement, signed by an authorized representative of Subrecipient and the Deputy Director. (b) Requests for Payments. To receive each payment under this Agreement, Subrecipient shall submit to the City a written reimbursement request or invoice in a form approved by City, along with such supporting documentation as may be requested by the City to verify Subrecipient's performance of the Services for which the payment is requested. Reimbursement requests shall be submitted no more frequently than two times per month. Payments will be adjusted by the City in accordance with fund advances, if any, and program income balances available in Subrecipient accounts. In addition, the City reserves the right to liquidate funds available under this Agreement for costs incurred by the City on behalf of the Subrecipient. 3.3 Payments Subject to Availability of HOME Funds. City's obligation to provide payments to Subrecipient hereunder is subject to City's receipt of HOME Funds from HUD pursuant to the HOME Program. 3.4 Accounting. Subrecipient shall, upon request, provide City with an accounting report, in form and content reasonably satisfactory to City, of any funds disbursed by City pursuant to Section 3.2. ARTICLE 4 INSURANCE AND INDEMNIFICATION 4.1 Insurance. Without limiting City's right to indemnification, Subrecipient shall secure prior to commencing the performance of any Services under this Agreement, and maintain during the Term of this Agreement, insurance coverage as set forth in this Section. (a) Required Insurance. Subrecipient shall secure and maintain the following coverage: l 8-6743/185590/MV 13 (1) Workers' Compensation Insurance as required by California statutes; (ii) Comprehensive General Liability Insurance, or Commercial General Liability Insurance, including coverage for Premises and Operations, Contractual Liability, Personal Injury Liability, Products/Completed Operations Liability, Broad -Form Property Damage, Independent Contractor's Liability and Fire Damage Legal Liability, in an amount of not less than One Million Dollars ($1,000,000.00) per occurrence, combined single limit, written on an occurrence form; and (iii) Comprehensive Automobile Liability coverage, including — as applicable — owned, non -owned and hired autos, in an amount of not less than One Million Dollars ($1,000,000.00) per occurrence, combined single -limit, written on an occurrence form. The Deputy Director, with the consent of City's Risk Manager is hereby authorized to modify the requirements set forth above in the event he or she determines that a modification, whether an increase or decrease, is in City's best interest. (b) Required Clauses in Policies. Each insurance policy required by this Agreement shall contain the following clauses: "This insurance shall not be canceled or allowed to lapse without at least ten (10) days' prior written notice given to the City Clerk of the City of Huntington Beach, 2000 Main Street, Huntington Beach, CA 92648." "It is agreed that any insurance maintained by the City of Huntington Beach shall apply in excess of and not contribute with insurance provided by this policy." Each insurance policy required by this Agreement, excepting policies for workers' compensation, shall contain the following clause: "The City of Huntington Beach, its officials, agents, employees, representative, and volunteers are added as additional insureds as respects operations and activities of, or on behalf of the named insured, performed under contract with the City of Huntington Beach. Subrecipient hereby agrees to waive subrogation which any insurer of the Subrecipient may acquire from the Subrecipient by virtue of the payment of any loss. If requested by City, Subrecipient agrees to obtain and deliver to City an endorsement from Subrecipient's general liability and automobile insurance insurer to effect this waiver of subrogation. (c) Property Insurance. Subrecipient shall further comply with the insurance requirements of 24 CFR 84.31. 18-6743/185590/MV 14 (d) Required Certificates and Endorsements. Prior to commencement of any Services under this Agreement, the Subrecipient shall deliver to City (i) insurance certificates confirming the existence of the insurance required by this Agreement, and including the applicable clauses referenced above, and (ii) endorsements to the above -required policies, which add to these policies the applicable clauses referenced above. Such endorsements shall be signed by an authorized representative of the insurance company and shall include the signator's company affiliation and title. Should it be deemed necessary by City, it shall be the Subrecipient's responsibility to see that City receives documentation, acceptable to City, which sustains that the individual signing such endorsements is indeed authorized to do so by the insurance company. Also, City reserves the right at any time to demand, and to receive within a reasonable time period, certified copies of any insurance policies required under this Agreement, including endorsements effecting the coverage required by these specifications. (e) Remedies for Defaults Re: Insurance. In addition to any other remedies City may have if the Subrecipient fails to provide or maintain any insurance policies or policy endorsements to the extent and within the time herein required, City may, at its sole option: (i) Obtain such insurance and deduct and retain the amount of the premium for such insurance from any sums due under the Agreement; (ii) Order the Subrecipient to stop work under this Agreement and/or withhold any payment(s) which become due to the Subrecipient hereunder until the Subrecipient demonstrates compliance with the requirements hereof; or (ill) Terminate this Agreement. Exercise of any of the above remedies, however, is an alternative to other remedies City may have and is not the exclusive remedy for the Subrecipient's failure to maintain insurance or secure appropriate endorsements. Nothing herein contained shall be construed as limiting in any way the extent to which the Subrecipient may be held responsible for payment of damages to persons or property resulting from the Subrecipient's or its subcontractor's performance of the Services covered under this Agreement. 4.2 Indemnification. (a) As respects acts, errors or omissions in the performance of Services under this Agreement, the Subrecipient agrees to defend, indemnify and hold harmless City, its officers, agents, employees, representatives and volunteers from and against any and all claims, demands, defense costs, liability or consequential damages of any 18-6743/ 185590/MV 15 kind or nature arising directly out of the Subrecipient's negligent acts, errors or omissions in the performance of Services under the terms of this Agreement. (b) As respects all acts or omissions which do not arise directly out of the performance of Services, including but not limited to those acts or omissions normally covered by general and automobile liability insurance, Subrecipient agrees to indemnify, defend (at City's option), and hold harmless City, its officers, agents, employees, representatives, and volunteers from and against any and all claims, demands, defense costs, liability, or consequential damages of any kind or nature arising out of or in connection with Subrecipient's performance or failure to perform, under this Agreement; excepting those which arise out of the sole negligence of City. ARTICLE 5 ADMINISTRATIVE REQUIREMENTS 5.1 Financial Management. (a) Accounting Standards. Subrecipient agrees to comply with 24 CFR 84.21 through 84.28 and agrees to adhere to the accounting principles and procedures required therein, utilize adequate internal controls, and maintain necessary source documentation for all costs incurred. (b) Cost Principles. Subrecipient shall administer its program in conformance with OMB Circulars A-122, "Cost Principles for Non -Profit Organization." These principles shall be applied for all costs incurred whether charged on a direct or indirect basis. 5.2 Documentation, Recordkeeping, Reporting and Monitoring. Subrecipient shall maintain documents and records, prepare and submit reports, and permit City to monitor Subrecipient's activities all in accordance with the requirements set forth in Exhibit B and applicable laws and regulations. All requirements set forth in such Exhibit B are incorporated herein as if set forth in full in this Agreement. 5.3 Use and Reversion of Assets. The use and disposition of property and equipment under this Agreement shall be in compliance with the requirements of 24 CFR Part 84 and 24 CFT 92.504, as applicable. The Subrecipient shall transfer to the City any HOME Funds on hand and any accounts receivable attributable to the use of HOME Funds under this Agreement at the time of the earliest to occur of expiration, cancellation, or termination. 5.4 Ownership of Documents. All documents and materials, both tangible and intangible, furnished by or through the City to Subrecipient pursuant to this Agreement are and shall remain the property of City and shall be returned to City upon the earliest to occur of expiration, cancellation, or termination of this Agreement. All documents and materials prepared by Subrecipient under or related to this Agreement shall become the property of City at the time of payment to Subrecipient of all fees, if any, for their preparation, and shall be delivered to City by Subrecipient at the request of City, and in any event upon the earliest to occur of expiration, cancellation, or termination of this Agreement. 18-6743/185590/N4V 16 ARTICLE 6 PERSONNEL & PARTICIPANT CONDITIONS 6.1 Civil Rights. (a) Compliance. The Subrecipient agrees to comply with the Huntington Beach Municipal Code, Government Code Section 4450, et seq., the Unruh Civil Rights Act, Civil Code Section 51, et seq., Title VI of the Civil Rights Act of 1964, as amended, Title VIII of the Civil Rights Act of 1968 as amended, Section 104(b) and Section 109 of Title 1 of the Housing and Community Development Act of 1974, as amended, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990, the Age Discrimination Act of 1975, Executive Order 11063, and Executive Order 11246 as amended by Executive Orders 11375, 11478, 12107 and 12086. (b) Nondiscrimination. The Subrecipient agrees to comply with (1) the requirements of 24 CFR Part 5, subpart A, which relate to nondiscrimination and equal opportunity; (2) the nondiscrimination requirements of Section 282 of the HOME Investment Partnerships Act, 42 U.S.C. Section 12701, et seq. (c) Section 504. The Subrecipient agrees to comply with all federal regulations issued pursuant to compliance with Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), which prohibits discrimination against the individuals with disabilities or handicaps in any federally assisted program. 6.2 Affirmative Action. (a) Executive Order 11246. The Subrecipient agrees that it shall be committed to carry out pursuant to the City's specifications an Affirmative Action Program in keeping with the principles as provided in President's Executive Order 11246 of September 24, 1966. (b) Women- and Minority -Owned Businesses (W/MBE). The Subrecipient will use its best efforts to afford small businesses, minority business enterprises, and women's business enterprises the maximum practicable opportunity to participate in the performance of this Agreement. As used in this Agreement, the terms "small business" means a business that meets the "minority and women's business enterprise" means a business at least fifty-one percent (51 %) owned and controlled by minority group members or women. For the purpose of this definition, "minority group members" are Afro-Americans, Spanish-speaking, Spanish surnamed or Spanish -heritage Americans, Asian -Americans, and American Indians. The Subrecipient may rely on written representations by businesses regarding their status as minority and female business enterprises in lieu of an independent investigation. 18-6743i 185590/MV 17 (c) Equal Employment Opportunity and Affirmative Action (EEO/AA) Statement. The Subrecipient will, in all solicitations or advertisements for employees placed by or on behalf of the Subrecipient, state that it is an Equal Opportunity or Affirmative Action employer. (d) Subcontract Provisions. The Subrecipient will include the provisions of Sections 6.1, Civil Rights, and 6.2, Affirmative Action, in every subcontract or purchase order, specifically or by reference, so that such provisions will be binding upon each of its own sub-subrecipients or subcontractors. 6.3 Employment Restrictions. (a) Prohibited Activity. The Subrecipient is prohibited from using HOME Funds provided herein or personnel employed in. the administration of the program for: political activities; inherently religious activities; lobbying; political patronage; and nepotism activities. (b) Labor Standard. The Subrecipient agrees to comply with the requirements of the Secretary of Labor in accordance with the Davis -Bacon Act as amended, the provisions of Contract Work Hours and Safety Standards Act (40 U.S.C. 327 et seq.) and all other applicable federal, state and local laws and regulations pertaining to labor standards insofar as and when those acts apply to the performance of this Agreement. The Subrecipient agrees to comply with the Copeland Anti -Kick Back Act (18 U.S.C. 874 et seq.) and the implementing regulations thereto issued by the U.S. Department of Labor at 29 CFR Part 5. The Subrecipient shall maintain documentation that demonstrates compliance with applicable hour and wage requirements. (c) Prevailing Wage. The Subrecipient agrees that, to the extent applicable, all contractors engaged under contracts for construction, renovation or repair work financed in whole or in part with assistance provided under this Agreement shall comply with the regulations of the Department of Labor, under 29 CFR Parts 1, 3, 5 and 7 and California Labor Code Section 1720, et seq. governing the payment of wages and ratio of apprentices and trainees to journey workers. The Subrecipient shall cause or require to be inserted in full, in all such contracts subject to such regulations, provisions meeting the requirements of this paragraph. (d) Section 3 Clause. The Subrecipient agrees, to the extent applicable, to comply with Section 3 of the HUD Act of 1968, as amended, and as implemented by the regulations set forth in 24 CFR 135. 6.4 Conduct (a) Assignment. The Subrecipient shall not assign or transfer any interest in this Agreement without the prior written consent of the City thereto; provided, however, that claims for money due or to become due to the Subrecipient from the City under this Agreement may be assigned to a bank, trust company, or other 18-6743/185590/MV 18 financial institution without such approval. Notice of any such assignment or transfer shall be furnished promptly to the City. (b) Subcontracts. (i) Approvals. The Subrecipient shall not enter into any subcontracts with any entity, agency or individual in the performance of this Agreement without the written consent of the City prior to the execution of such agreement. (ii) Monitoring. The Subrecipient will monitor all subcontracted services on a regular basis to assure contract compliance. Results of monitoring efforts shall be summarized in written reports and supported with documented evidence of follow-up actions taken to correct areas of noncompliance. (iii) Content. The Subrecipient shall cause all of the provisions of this Agreement in its entirety to be included in and made a part of any subcontract executed in the performance of this Agreement. (iv) Selection Process. The Subrecipient shall undertake to insure that all subcontracts let in the performance of this Agreement shall be awarded on a fair and open competition basis in _accordance with applicable procurement requirements. Executed copies of all subcontracts shall be forwarded to the City along with documentation concerning the selection process. (c) Hatch Act. The Subrecipient agrees that no funds provided, nor personnel employed under this Agreement, shall be in any way or to any extent engaged in the conduct of political activities in violation of Chapter 15 of Title V of the U.S.C. (d) Conflict of Interest. The Subrecipient agrees to abide by the provisions of 24 CFR 84.42 and 92.356, which include (but are not limited to) the following: (i) The Subrecipient shall maintain a written code or standards of conduct that shall govern the performance of its officers. employees or agents engaged in the award and administration of contracts supported by HOME Funds. (ii) No employee, officer or agent of the Subrecipient shall participate in the selection, or in the award, or administration of, a contract supported by HOME Funds if a conflict of interest, real or apparent, would be involved. (iii) No covered persons who exercise or have exercised any functions or responsibilities with respect to HOME -assisted activities, or who are in a position to participate in a decision -making process or gain inside information with regard to such activities, may obtain a financial interest in 18-6743/185590/MV 19 any contract, or have a financial interest in any contract, subcontract, or agreement with respect to the HOME -assisted activity, or with respect to the proceeds from the HOME -assisted activity, either for themselves or those with whom they have business or immediate family ties, during their tenure or for a period of one (1) year thereafter. For purposes of this paragraph, a "covered person" includes any person who is an employee, agent, consultant, officer, or elected or appointed official of the City, the Subrecipient, or any designated public agency. (e) Lobbying. The Subrecipient hereby certifies that: (1) No federal appropriated funds have been paid or will be paid, by or on behalf of it, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement; (ii) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, it will complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions; and (iii) It will require that the language of paragraph (iv) of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all Subrecipients shall certify and disclose accordingly. (f) Lobbying Certification. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352 Title 31, US.C. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. (g) Religious Activities. The Subrecipient agrees that funds provided under this Agreement will not be utilized for inherently religious activities such as worship, religious instruction, or proselytization. 18-6743/185590/MV 20 ARTICLE 7 GENERAL CONDITIONS 7.1 General Compliance. The Subrecipient agrees to comply with the requirements of the HOME Program in the administration and implementation of the TBRA Program and this Agreement. The Subrecipient shall carry out each activity in compliance with all regulations described in subpart H of 24 CFR Part 92, except that the Subrecipient does not assume the City's responsibilities for environmental review under 24 CPR 92.352 and the intergovernmental review process described in 24 CFR 92.357 does not apply to the Subrecipient. The Subrecipient also agrees to comply with all other applicable federal, state and local laws, regulations, and policies governing the funds provided under this Agreement. The Subrecipient further agrees to utilize funds available under this Agreement to supplement rather than supplant funds otherwise available. 7.2 Familiarity with Services; Qualified Personnel. (a) By executing this Agreement, Subrecipient represents and warrants that Subrecipient (i) has thoroughly investigated and considered the Services to be performed, (ii) has carefully considered how the Services should be performed, and (iii) fully understands the requirements, difficulties and restrictions attending the performance of the Services under this Agreement. (b) Subrecipient represents that Subrecipient has or will secure and maintain, at Subrecipient's sole cost and expense, all qualified and licensed personnel required to perform the Services. Staff and any additional personnel hired by Subrecipient 'shall be employees of Subrecipient. Such personnel shall not be deemed to be employees of City or to have any contractual relationship with City. Such Personnel shall be authorized or permitted under state and local law to perform the Services. 7.3 Independent Contractor. In performing under this Agreement, Subrecipient is and shall at all times be acting and performing as an independent contractor to City, performing its duties in accordance with its own judgment. City shall neither have nor exercise any control or direction over the methods by which Subrecipient performs its work and function nor shall City have the right to interfere with such freedom or action or prescribe rules or otherwise control or direct the manner in which such services are performed. The sole interest of the City in the Services performed by the Subrecipient is that such Services be performed in a legal competent, efficient and satisfactory manner. Nothing contained herein shall cause the relationship between the parties to this Agreement to be that of employer and employee. Subrecipient shall not have the authority to obligate City to any contract, obligation, or undertaking whatsoever and shall make no representation, either oral or in writing. 18-6743/185590/MV 21 7.4 Subrecipient Representative. Subrecipient hereby designates Carol Williams as its Project Manager for the TBRA Program ("Subrecipient's Representative"). Subrecipient's Representative shall supervise and direct the Services, using his or her best skill and attention, and shall be responsible for all means, methods, techniques, sequences and procedures and for the satisfactory coordination of all portions of the Services under this Agreement. 7.5 Nepotism. Subrecipient shall not hire or permit the hiring of any person to fill a position funded through this Agreement if a member of the person's immediate family is employed in an administrative capacity by City's HOME Program or any department of the City which is administering the HOME Program. For the purposes of this section, the term "immediate- family' means spouse, child, mother, father brother, sister, brother-in-law, sister-in-law, father-in-law, mother-in-law, son-in-law, daughter-in-law, aunt, uncle, stepparent and stepchild. The term "administrative capacity" means having selection, hiring, supervisory or management responsibilities, including serving on the governing body of City. 7.6 Hold Harmless. The Subrecipient shall indemnify, hold harmless, and defend the City and their elected officials, officers, employees and agents and shall pay for expenses incurred by the City for any and all claims, actions, suits, charges and judgments whatsoever related in any manner to or that arise out of the Subrecipient's performance or nonperformance of the Services or subject matter called for in this Agreement. 7.7 City Recognition. The Subrecipient shall insure recognition of the role of the City in providing Services through this Agreement. All activities, facilities and items utilized pursuant to this Agreement shall be prominently labeled as to funding source. 7.8 Notices. Any approval, disapproval, demand, document or other notice ("Notice") which any party may desire to give to the other party under this Agreement must be in writing and may be given either by (i) personal service, (ii) delivery by reputable document delivery service such as Federal Express that provides a receipt showing date and time of delivery, (iii) facsimile transmission, or (vi) mailing in the United States mail, certified mail, postage prepaid, return receipt requested, addressed to the address of the party as set forth below, or at any other address as that party may later designate by Notice. Service shall be deemed conclusively made at the time of service if personally served; upon confirmation of receipt if sent by facsimile transmission; the next business if sent by overnight courier and receipt is confirmed by the signature of an agent or employee of the party served; the next business day after deposit in the United States mail, properly addressed and postage prepaid, return receipt requested, if served by express mail; and three (3) days after deposit in the United States mail, properly addressed and postage prepaid, return receipt requested, if served by certified mail. 18-6743/185590/MV 22 Subrecipient: Interval House Carol Williams Interval House 6615 E. Pacific Coast Highway, 4170 Long Beach, CA 90803 City: City Clerk City of Huntington Beach 2000 Main Street Huntington Beach, CA 92648 With copies to: Kellee Fritzal Office of Business Development 2000 Main Street Huntington Beach, CA 92648 Such addresses may be changed by Notice to the other party(ies) given in the same manner as provided above. 7.9 Amendment and Waiver. This Agreement may be amended, modified, or supplemented only by a writing executed by each of the parties. Any party may in writing waive any provision of this Agreement to the extent such provision is for the benefit of the waiving party. No action taken pursuant to this Agreement, including any investigation by or on behalf of any party, shall be deemed to constitute a waiver by that party or its or any other party's compliance with any representations or warranties or with any provision of this Agreement. 7.10 Entire Agreement. This Agreement, including all Exhibits attached hereto, embodies the entire agreement and understanding between the parties pertaining to the subject matter of this Agreement and supersedes all prior agreements, understandings, negotiations, representations, and discussions, whether verbal or written, of the parties pertaining to the subject matter. In the event of a conflict between this Agreement, on one hand, and any Exhibit attached hereto, on the other hand, the provisions of this Agreement shall control; provided, if it is possible to comply with the requirements of this Agreement and the Exhibits, the parties shall do so. The following Exhibits are attached to this Agreement and incorporated herein: Exhibit A TBRA Program Operating Guidelines Appendix A Initial Qualification Form Appendix B TBRA Application Appendix C Declaration of Homelessness Appendix D Housing Quality Standards (HQS) Inspection Checklist 18-6743/185590/MV 23 Appendix E Landlord Agreement Appendix F Tenant Protection Agreement Appendix G Rent Reasonableness Standard Appendix H Orange County Housing Authority — Utility Allowance Schedule Appendix I Participant Agreement Appendix J Case Management and Self Sufficiency Program Policies and Procedures Exhibit B Documentation, Recordkeeping, Reporting and Monitoring Requirements Exhibit C Gross Income Calculation Form Exhibit D Household Budget Worksheet Exhibit E Lead -Based Hazard Information Pamphlet "Protect Your Family from Lead in your Home" Exhibit F Budget Exhibit G Housing Quality Standards (HQS) Inspection Checklist 7.11 Governing Law. The validity, construction, and performance of this Agreement shall be governed by the laws of the State of California. 7.12 Non -Liability of Members, Officials and Employees of City. No member, official or employee of City shall be personally liable to Subrecipient, or any successor in interest, in the event of any Default or breach by City or for any amount which may become due to Subrecipient or Subrecipient's successors, or on any obligation under the terms of this Agreement. Subrecipient hereby waives and releases any claim Subrecipient may have against the member, officials or employees of City with respect to any Default or breach by City or for any amount which may become due to Subrecipient or Subrecipient's successors, or any obligations under the terms of this Agreement. Subrecipient makes such release with the full knowledge of Civil Code Section 1542 and hereby waives any and all rights thereunder to the extent of this release, if such Section 1542 is applicable. Section 1542 of the Civil Code provides as follows: "A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING ] 8-6743/l 85590/MV 24 THE RELEASE, WHICH IF KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR." ARTICLE 8 ENFORCEMENT; TERMINATION 8.1 Events of Default. (a) For purposes of this Agreement, the word "Default" shall mean the failure of Subrecipient to perform any of Subrecipient's duties or obligations or the breach by Subrecipient of any of the terms and conditions set forth in this Agreement; any failure by Subrecipient to comply with any of the rules, regulations or provisions referred to herein, or such statutes, regulations, executive orders, and HUD guidelines, policies or directives as may become applicable at any time; any ineffective or improper use of funds provided under this Agreement; or submission by the Subrecipient to the City reports that are incorrect or incomplete in any material respect. In addition, Subrecipient shall be deemed to be in Default upon Subrecipient's (i) application for, consent to, or suffering of, the appointment of a receiver, trustee or liquidator for all or a substantial portion of its assets, (ii) making a general assignment for the benefit of creditors, (iii) being adjudged- bankrupt, filing a voluntary petition or suffering an involuntary petition under any bankruptcy, arrangement, reorganization or insolvency law (unless in the case of an involuntary petition, the same is dismissed within thirty (30) days of such filing), or (v) suffering or permitting to continue unstayed and in effect for fifteen (15) consecutive days any attachment, levy, execution or seizure of all or a substantial portion of Subrecipient's assets or of Subrecipient' s interests hereunder. (b) City shall not be deemed to be in Default in the performance of any obligation required to he performed by City hereunder unless and until City has failed to perform such obligation for a period of thirty (30) days after receipt of written notice from Subrecipient specifying in reasonable detail the nature and extent of any such failure; provided, however, that if the nature of City's obligation is such that more than thirty (30) days are required for its performance, then City shall not be deemed to be in Default if City shall commence to cure such performance within such thirty (30) day period and thereafter diligently prosecute the same to completion. 8.2 Institution of Legal Actions. In addition to any other rights and remedies, and subject to the restrictions otherwise set forth in this Agreement, either party may institute an action at law or in equity to seek the specific performance of the terms of this Agreement, to cure, correct or remedy any Default, to recover damages for any Default or to obtain any other remedy consistent with the purpose of this Agreement. Such legal actions must be instituted in the Superior Court of the County of California, State of 18-6743/185590/MV 25 California or in the United States District Court for the Central District of California. 8.3 Acceptance of Service of Process. In the event that any legal action is commenced by the Subrecipient against City, service of process on City shall be made by personal service upon the City Clerk or in such other manner as may be provided by law. In the event that any legal action is commenced by City against the Subrecipient, service of process on the Subrecipient shall be made by personal service upon Subrecipient's Representative or in such other manner as may be provided by law. 8.4 Rights and Remedies Are Cumulative. Except as otherwise expressly stated in this Agreement, the rights and remedies of the parties are cumulative, and the exercise by either party of one or more of such rights or remedies shall not preclude the exercise by it, at the same or different times, of any other rights or remedies for the same Default or any other Default by the other party. 8.5 Inaction Not a Waiver of Default. Any failures or delays by either party in asserting any of its rights and remedies as to any Default shall not operate as a waiver of any Default or of any such rights or remedies, or deprive either such party of its right to institute and maintain any actions or proceedings which it may deem necessary to protect, assert or enforce any such rights or remedies. 8.6 Attorney's -Fees. City and Subrecipient agree that in the event of litigation to enforce this Agreement or terms, provisions and conditions contained herein, to terminate this Agreement, or to collect damages for a Default hereunder, the prevailing party shall not be entitled to costs and expenses, including reasonable attorney's fees, incurred in connection with such litigation, such that each party shall be responsible for their costs and attorneys' fees. 8.7 Termination. (a) Termination for Cause. In accordance with 24 CFR 85.43, the City may suspend or terminate this Agreement in the event of a Default by the Subrecipient under this Agreement. Subrecipient may suspend or terminate this Agreement if City fails to make payments to Subrecipient as required herein. (b) Termination for Convenience. In accordance with 24 CFR 85.44, this Agreement may also be terminated for convenience by either the City or the Subrecipient, in whole or in part, by setting forth the reasons for such termination, the date the termination will be effective, and, in the case of partial termination, the portion to be terminated. However, if in the case of a partial termination, the City determines that the remaining portion of the award will not accomplish the purpose for which the award was made, the City may terminate the award in its entirety. 18-6743/185590/MV 26 IN WITNESS WHEREOF, the parties have executed this HOME Recipient Agreement (Tenant Based Rental Assistance) as of the Effective Date, which is the date of the City Council approving this Agreement. SUBRECIPIENT: CITY: INTERVAL HOUSE, a California nonprofit corporation By: &�h.Gt. Print name ITS: (circle one) Chairm res ice President AND By:� 0AV0 Iti 111I cLvt Ls print name ITS: (circle one) Secr5xyXhief Financial QffidatAsst< Secretary —Treasurer G l( t ji' C] v*__ �i ►--� p� COUNTERPART CITY OF HUNTINGTON BEACH, a municipal corporation and charter city Mayor ATTEST: City Clerk APPROVED AS TO FORM: By: City Attorney M V INITIATED AND APPROVED: By: Deputy Director of Business Development REVIEWED AND APPROVED: City Manager 18-6743/185590/MV 27 IN WITNESS WHEREOF, the parties have executed this HOME Recipient Agreement (Tenant Based Rental Assistance) as of the Effective Date, which is the date of the City Council approving this Agreement. SUBRECIPIENT: CITY: INTERVAL HOUSE, a California nonprofit corporation IC Print name ITS: (circle one) Chairman/President/Vice President IC AND print name ITS: (circle one) Secretary/Chief Financial Officer/Asst. Secretary — Treasurer COUNTERPART CITY OF HUNTINGTON BEACH, a municipal coU)oration and charter city Mayor ATTEST: n - J�4�`LQ City C qrk Ie1».Z6],F/aOX.11% di�1IIs).1kyja y:'QKy Attorney M V XNITIATED AND APPROVED: By: (eputy Direct of Business Development REVIEWJ&) AN121 APPROVED: City *'ia*r 18-6743/185590/MV 27 Interval House Exhibit A Operating Guidelines Includes: Appendix A Appendix B Appendix C Appendix D Appendix E Appendix F Appendix G Appendix H Appendix I Appendix J Initial Qualification Form TBRA Application Declaration of Homelessness Housing Quality Standards (HQS) Inspection Checklist Landlord Agreement Tenant Protection Agreement Rent Reasonableness Standard Orange County Housing Authority— Utility Allowance Schedule Participant Agreement Case Management and Self Sufficiency Program Policies and Procedures City of Huntington Beach Tenant -Based Rental Assistance Program Operating Guidelines I. Program Overview The City of Huntington Beach (City) has established a Tenant -Based Rental Assistance (TBRA) program (Program) that follows all the requirements of the HOME Program, as set forth in the HOME Program under Section 24, Part 92, of the code of Federal Regulations (24 CFR 92). In 2015, the City published a Request for Proposals (RFP) and selected Interval House to administer the Program through 2020. The City will evaluate the impact of the Program on homeless individuals and families at the end of the term to determine the merits of extending the program and the effectiveness of the services provided by Interval House. Key indicators of success will include the ability to transition off the Program and remain housed without assistance for at least six months, increases in earned income, and sustainable rent burden (at or below 30% of family income). The Program will provide short and medium -term rental assistance was well as housing relocation and stabilization services for homeless and at -risk of homeless households from Huntington Beach, who have extremely -low income. All at -risk of homeless households shall be approved by the Deputy Director of Business Development. The Program will meet the City's Investment Criteria by targeting program assistance up to 11 homeless households, all with incomes at or below 30% AMI and preference given to veterans, seniors and victims of domestic violence. Fifty percent (50%) of Client served will be referred from the Huntington Beach Homeless Task Force. The procedures set forth herein establish the tenant selection guidelines for the Program, provide the necessary operating structure for the Program and clarify the roles and responsibilities of Interval House and the City. II. Marketing, Outreach and Application Process A. Marketing and Outreach Interval House is responsible for marketing and outreach activities to find prospective Eligible Households interested in the Program. Interval House will conduct -community presentations, outreach, training to community organizations, and participate in community events to educate on TBRA resources available. Additionally, Interval House will continue to partner with Huntington Beach Police Department, OC211, Huntington Beach Homeless Task Force, and other housing providers to refer eligible residents of Huntington Beach eligible for TBRA assistance. Interval House will provide quarterly reports to the City that shall describe the marketing and outreach efforts for the quarter. All marketing need to be done to meet all affirmative marketing requirements. B. Waiting List Once the Program has reached maximum enrollment, estimated at 11 households over the one-year contract period, Interval House shall maintain a waiting list of prospective Eligible Households. This list will be prioritized as follows: ■ Clients who have been assessed for TBRA eligibility, completed intake process, and ready for housing placement. ■ Clients who have been assessed for TBRA eligibility, completed intake process, and searching for housing. ■ Clients who have been assessed for TBRA eligibility and pending intake. ■ Ready for housing placement means that the household has found a housing unit that meets TBRA requirements (many landlords won't accept third party payments, rent requested by landlord is too high, won't allow unit inspection, etc.) ■ Priority ranking will be given for Homeless Category 1 (24 CRF 91, 582 and 583) - literally homeless participants will come from the streets or other locations not meant for human habitation, emergency shelters, or safe havens. Targeted preference will be given to veterans, seniors, and victims of domestic violence (Homeless Category 4) to support the City's investment priorities. Within these categories, households will be helped on a first come — first served basis, based on the date and time of application completed. C. Intake Process As part of the intake process, Interval House will meet with the prospective Eligible Household to conduct a needs assessment and complete an Initial Qualifications Form (Appendix A). If the Program has reached maximum capacity, Interval House shall review the applicant to assess if other services may be offered while the applicant is waiting for a slot to open in the Program. As part of the intake process, Interval House shall also request and/or assist the prospective Eligible Household with the completion of the following documents: ■ TBRA Application (Appendix B) 0 Declaration of Homeless Status or Declaration of At -Risk of Homelessness Status (Appendix C) D. Guidance for Eligible Households Interval House will meet with the prospective Eligible Households throughout the application process and will continue to meet with and counsel each Eligible Household regarding the Program, the Eligible Household's responsibilities as participants of the Program, and the goals and objectives of the Program. III. Determination of Eligibility The Program will utilize HOME Program funds for supportive services and rental assistance. As such, the applicants must meet the eligibility qualifications of the HOME Program. Eligibility for services offered by the Program shall adhere to the following selection criteria: A. Income Eligible Households ■ To receive supportive services as well as rental assistance under the HOME Program, the Applicant's total household income must be at or below 30% of the Orange County area median income (AMI). However, once the Applicant is part of the Program, the household income can increase up to 80% of the AMI before Interval House must give notice of termination from the Program. ■ Income limits for extremely -low income households are established annually for the HOME Program by HUD for the Orange County income limit area. ■ Gross Annual Income shall be determined in accordance with 24 CFR 5.609, with the allowable exclusions from income established at 24 CFR 5.611. ■ Gross Annual Income means the gross amount of income from all sources, including assets, for all adult household members that is anticipated to be received prospectively during the 12-month period following the date of application and before any deductions are taken. ■ Interval House will determine and verify eligibility for assistance under the Program through the review of income source documents. As outlined in the revised HOME rules published in July 2013, applicants must provide evidence of income for the two (2) most recent months. Acceptable source documents include wage statements, check stubs, entitlement verification from another government agency and bank statements. The definition of income for the purposes of the Program is located at 24 CFR Part 5 (often referred to as the Section 8 definition). In cases where no evidence of income (third -party verification) is available, Interval House may allow clients to self -report their income. In such cases, Interval House staff will provide a written explanation for why they were unable to obtain third -party verification or documentation. ■ Interval House may also consider any likely changes in income when collecting income verification documentation. • Initial income verifications are valid for six months. If admission to the Program takes longer than 6 months, income verifications must be updated and reevaluated. After initial verification, income recertification shall be conducted annually. ■ Income verifications will be used for two purposes: To determine eligibility for services. A determination of eligibility will be completed as part of the admissions process and thereafter annually. Income information will be used to establish the household's initial contribution toward rent, which shall be set at 30% of the household income. The household's initial contribution will remain unchanged for at least six months. B. Current Residents of the City of Huntington Beach Due to the nature of the population served by the Program, it may not be possible to obtain traditional proof of residency documentation such as utility bills. The following documentation can be accepted to establish that an applicant household qualifies for the Huntington Beach live/work preference: ■ Documentation from a Huntington Beach school that the children in the household have been enrolled in and attending the school for at least the last 90 days from the time of admission into the Program. ■ Documentation from a partner agency, such as the Huntington Beach Police Department, evidencing that the family is known to be homeless in Huntington Beach. ■ Proof that the applicant's last place of stable residency was in the City of Huntington Beach. Verification from a landlord is acceptable. ■ Proof that an adult member of the household is working or has been recently hired to work in Huntington Beach. C. Currently Homeless or At -Risk of Homelessness ■ At -Risk of Homelessness -refers to a household that is at imminent risk of being evicted due to an economic hardship in paying rent or staying current with rent. (Category 2 of HUD Homeless Definition) ■ Homelessness refers to a household who meets the HUD Homeless Definition at 24 CRF 91, 582 and 583: Category 1 (literally homeless) and Category 4 (fleeing/attempting to flee violence and living in a place described in Category 1). D. Preferences The following summarizes the populations that Interval House will target (note that the total percentages do not total to 100%): Program Targeted Populations Veterans 40% Seniors 40% Victims of Domestic Violence 40% Homeless 30% E. Annual Eligibility Verification ■ Interval House will requalify each Eligible Household, including examination of source documentation, on an annual basis. ■ Interval House may request that a participating Eligible Household provide verification(s) more often than annually, as reasonably necessary to confirm continued qualification and eligibility for the Program. ■ Interval House will provide written notice to each applicant stating whether the Eligible Household was determined to be eligible for continued assistance under the Program. IV. Selection of Housing A. Housing Unit Selection Eligible Households must be residents of Huntington Beach and may elect to rent any Housing Unit in the City so long as the unit meets federal housing quality standards (HQS) or such other standards as may be made applicable to the Program by HOME Program statues and/or regulations, specifically including Uniform Physical Condition Standards (UPCS) and passes a rent reasonableness test. Due to the nature of the population served by the Program, it is expected that Interval House will assist Eligible Households with finding and selecting an appropriate Housing Unit that meets all program requirements. If an appropriate Housing Unit cannot be located within the City boundaries, a Housing Unit can be located outside of the City boundaries when housing is not suitable within City boundaries. While Interval House can refer Eligible Households to appropriate Housing Units, households may not be required to select a particular Housing Unit. Rental assistance under the Program is only provided for Housing Units that meet the criteria established by the City of Huntington Beach HOME/TBRA Program. B. Occupancy Standards The number of persons in each Eligible Household will determine the required unit type. Each household must comply with the two per bedroom plus one occupancy standard. The following table provides the occupancy standards by unit type: Unit Type One -bedroom Unit HouseholdNumber in Up to 3 Persons Two -bedroom Unit Up to 5 Persons Three -bedroom Unit Up to 7 Persons Four -bedroom Unit Up to 9 Persons C. Property Inspections Prior to occupancy of any Housing Unit by an Eligible Household, and again during the annual verification process, Interval House will have a certified HQS inspector, inspect each Housing Unit to ensure the unit complies with HQS as set forth in the HOME Program (24 CFR 92.2Sl), as well as all applicable state and local codes and ordinances, including zoning ordinances. Each HQS inspection will include the following: ■ Verification of the age of the Housing Unit (on Rent Reasonableness Form); ■ Completed HQS Inspection Form (HUD-S2S80); ■ Lead -based paint hazard assessment, dissemination of lead -based paint information pamphlet and disclosure form and lead -based paint reduction activities, if required; ■ Adequate opportunity for landlord to correct any deficiencies indicated in the HQS Inspection form to bring the Housing Unit into compliance; and ■ Verification that occupancy by the Eligible Household will comply with occupancy standards. The HQS Inspection Form is located in Appendix D. D. Rent Reasonableness Rental assistance paid on behalf of the Eligible Household must be in compliance with federal Rent Reasonableness requirements which require that rents paid by or on behalf of assisted households be similar to rents paid by non -assisted households. Rent Reasonableness reviews will be performed -by Interval House. The factors listed below shall be considered when determining rent comparability: ■ Location and age; ■ Unit size including the number of rooms and square footage or rooms; ■ The type of unit including construction type (e.g., single family, duplexes, garden, low-rise, high- rise); ■ The quality of the unit, which includes the building construction, maintenance and improvements; and ■ Amenities, services and utilities included in the rent. Interval House will follow both the rent reasonableness regulations established for the Housing Choice Voucher (HCV) program at 24 CFR 982.507 to evaluate rents. In the event that a rent request does not meet rent reasonableness requirements, Interval House shall attempt to negotiate a lower rent with the property owner. If the owner is not willing to accept a lower rent, the household must be instructed to search for another unit. Under no circumstances shall Interval House or the assisted household agree to pay more than approved through the rent reasonableness review. Additionally, the assisted household is not allowed to make up any difference in the rent offer. E. Coordination with Landlords Interval House will meet with and provide guidance to landlords participating in the Program regarding the requirements and procedures that impact landlords. i. Landlord Agreement (Appendix E) ■ Interval House will enter into a Landlord Agreement with each participating landlord or property owner. The Landlord Agreement will establish the security deposit assistance payment and the initial rental assistance payments to be paid on behalf of the household. The Agreement will also establish the participating household's initial share of the contract rent. The Agreement will also require the landlord to provide Interval House with notice of a lease termination, and reaffirm the tenant protections included in the Tenant Protection Agreement. ■ The Eligible Household's share of rent will be re-evaluated every 6 months. ■ This contract will have an initial term of 12 months. ii. Tenant Protection Agreement (Appendix F) ■ The landlord will be required to enter into a lease agreement with a term of 12 months with any Eligible Household occupying a Housing Unit. ■ The lease agreement will include a Tenant Protection Agreement that will be executed in connection with the lease between the landlord and the Eligible Household. ■ The Tenant Protection Agreement will include the following elements: ■ Prohibit the inclusion of the following provisions in the lease, as required by 24 CFR 92.253: ■ (1) Agreement to be sued; ■ (2) Treatment of property; ■ (3) Excusing owner from responsibility; ■ (4) Waiver of notice; ■ (5) Waiver of legal proceedings; ■ (6) Waiver of a jury trial; ■ (7) Waiver of right to appeal court decision; 0 (8) Tenant chargeable with cost of legal actions regardless of outcome; and ■ (9) Mandatory supportive services. ■ Confirm the landlord's obligation to maintain the Housing Unit in accordance with HQS, as established at 24 CFR 982.401. ■ Prohibit discrimination by the landlord against the Eligible Household. ■ Interval House will review the lease agreement to confirm its compliance with state law and all HOME Program requirements. V. Payment Standards, Rent Calculation, Term and Subsidy Reductions As authorized by HOME TBRA regulations, the Program will rely on a traditional rental assistance calculation. The model allows for the rent subsidy determination based on 30% of household income. A. Rent Assistance Calculation Interval House will complete a rental assistance calculation for each Eligible Household. The calculation will determine each household's Program subsidy and share of the rent. The maximum amount of monthly assistance that Interval House may pay on behalf of a family is the difference between the rent standard for the unit size and 30% of the household's monthly adjusted income. Each household's maximum rent subsidy will vary since the calculation involves the use of individualized factors such as the household's actual income and family size. The initial household contribution to rent will remain unchanged for at least six months. Minimum tenant contribution to rent under the Program is set at $50.00. This minimum is used if the maximum subsidy calculation would result in the household paying less than $50.00 towards the monthly rent (e.g. if 30% of the household's monthly adjusted income is less than $50.00). This minimum contribution may be waived in exceptional circumstances. B. Rent Reasonableness Standards The Program must use the Rent Reasonableness Standard (Appendix G) to calculate monthly rental assistance. The payment standards represent the cost of rent and utilities for moderately priced units in Huntington Beach. Payment standards are established by bedroom size. When utilities are included in the cost of renting a unit, that is, the owner assumes responsibility for payment for all utility services, the household's entire share of the housing costs will go directly to the owner. When the cost of utilities is not part of the rent, that is, the household is directly responsible for payment of utility services, the household's initial share will be determined by subtracting a utility allowance from 30% of the household's income. Interval House must use the Orange County Housing Authority utility allowance schedule (Appendix H) to determine the household's utility allowance. In these cases, the household's share of the rent is equal to 30% of the household's monthly adjusted income minus the applicable monthly utility allowance. Each household is responsible for paying their rent share directly to the landlord each month. If a selected Housing Unit is subject to contractual, statutory and/or regulatory affordability restriction, the monthly rental assistance payments will not exceed the difference between the required affordable rent amount for the Housing Unit and 30% of the Eligible Household's monthly adjusted income. i. Participant Agreement (Appendix I) Interval House will enter into a Participant Agreement with each participating client household. The Participant Agreement will establish the Eligible Household's responsibilities towards rent payments. The Agreement will establish the participating household's initial share of the contract rent, which will be adjusted every 6 months. ii. Term Interval House will provide rental assistance for an initial term of 6 months, which can be extended every 6-12 months, for a cumulative term of up to 24 months. Extensions will be granted at the discretion of Interval House and shall be based on continued Program compliance and ongoing need. Interval House will utilize the Gap Analysis and Income Re -Evaluation to assess ongoing need and adjust household's share of rent as appropriate. Households with income above 60% AMI will be notified about income eligibility limits. iii. Subsidy Reductions The participant's household income will be reevaluated every six months. If the household income has increased since the previous evaluation, the participant's monthly rent responsibility will be adjusted accordingly per Rent Assistance Calculation as stated in above section V. A. VI. Security Deposits As needed, Interval House will provide security deposit assistance to Eligible Households. Such assistance shall be the lesser of: ■ Two months approved rent for the Housing Unit; or ■ The standard security deposit required by the landlord for non -subsidized tenants. Security deposit assistance provided to participating households willbein the form of a grant. As such, the landlord can provide a security deposit refund directly to the household. Any disputes involving the return, or lack thereof, of a security deposit shall be settled by the tenant and landlord, as provided for in the lease. VII. Annual Recertification, Termination of Assistance and Returning Households A. Annual Recertification Recertification of income and Program eligibility will occur annually. Interval House will gather source documentation for participating households to determine annual income. Annual income must be calculated in accordance with 24 CFR Part 5. If the total household income is above 80% AMI, rental assistance must be terminated following a 30 day notification period. B. Termination of Rental Assistance Assistance can be terminated for the following reasons: ■ Eviction from the assisted rental unit based on behavioral issues and/or unlawful activity. ■ The family will be assisted by another rental assistance program such as the Section 8 Tenant -Based or Project -Based program. Participation in any other rental assistance program is considered a duplicative subsidy therefore all HOME funded rental assistance must terminate. C. Returning Participant Households As needed, participants may be allowed to return to the Program for either support services, rental assistance or both. A determination to allow re-entry shall be based on the following criteria: ■ Participants must have left the Program in good standing. To be in good standing, participants must have been engaged in their case management plan, voluntarily left the program (not in -lieu of termination) or have been released because their household income exceeded eligible limits. In general, participants will not be allowed to re-enter the Program if they were terminated for non- compliance. ■ At the discretion of Interval House, a request for readmission from a non -compliant household may be considered when compelling reasons exist. In such cases, re -admission will require concurrence from the City. ■ The Participant's previous rental assistance did not exceed 24 months. Cumulatively, participants will only be allowed to receive rental assistance for a maximum of 24 months. VIII. Self Sufficiency Program Interval House will request each Eligible Household receiving rental assistance payments to participate in a Self -Sufficiency Program administered by Interval House. The Case Management and Self - Sufficiency Program Policies and Procedures are outlined in Appendix J. The Self -Sufficiency Program provides participating households with intense case management, which is designed to assist participants move to self-sufficiency within a 12 to 24 month period. Income recertifications will be completed annually for participating households. If the participating household's income exceeds the low (80% AMI) income limits, Interval House must terminate the rental assistance. Listed below are some of the Self -Sufficiency Case Management Services offered by Interval House: A. Case Management The Interval House Case Management model maximizes client success by developing individualized service plans and addressing clients' specific needs in securing permanent housing and self-sufficiency. Clients will meet with their Case Manger on a minimum of a monthly basis to update goals, monitor progress, and ensure long-term housing stability. Self-sufficiency groups are also held weekly to assist with financial management, job development, life skills, personal empowerment, and accessing other resources needed to gain housing stability. B. Individualized Housing and Service Plan Participants meet with their Case Manager at intake and monthly to review their Goal Worksheet and Individualized Service Plan to help establish and identify participant goals and plans for housing, education, employment, financial (including budgeting and credit repair), legal, and other housing stabilization and relocation resources needed. C. Housing Search and Placement Interval House advocates assists clients with comprehensive housing search and placement into affordable permanent housing. Interval House has established close partnerships with permanent housing agencies, including affordable housing providers, apartment associations, and private landlords/owners. D. Legal Services Staff attorneys, legal advocates and volunteer attorneys provide comprehensive legal services and representation in multiple languages. Legal assistance includes lease agreements, legal advocacy, court accompaniment, and other legal issues affecting homeless and at -risk homeless persons and their children. E. Financial Management / Credit Repair Interval House has designed an 8-week comprehensive financial empowerment curriculum with weekly workshops conducted to assist program participants with credit repair, financial literacy, and job placement and retention. Assistance will also be provided to access mainstream financial benefits including social security, veteran's benefits, CaIWORKs, disability, unemployment, and other public assistance. F. Employment Assistance Obtaining self-sufficiency is a critical goal for families served by Interval House. Interval House Case Managers work with clients to identify interests, life experiences and talents that lend themselves to employment. Housing Advocates also: ■ Help clients develop resumes, complete job application and prepare for interviews; ■ Obtain educational scholarships through AmeriCorps and other sources to increase leadership skills and/or further their education; ■ Provide transportation solutions to job interviews and job -related activities; and ■ Provide job placement in career -level jobs and job retention assistance. G. Transportation Interval House provides support services at Community Service Center and Satellite sites in Huntington Beach conveniently accessible via public transportation routes or via home visits as needed. Interval House provides assistance with transportation via bus passes and accessing mainstream resources available for transportation through CaIWORKs and disability access. Interval House also maintains agreements with local taxi companies to provide emergency transportation assistance and works closely with the Huntington Beach Police Department to assist transport participants in crisis situations. H. Behavioral Health Interval House provides an array of individual and group counseling programs on -site and works closely with other mental health providers to address behavioral health needs of participants. Appendix A Initial Qualification Form Page 1 of 3 INTERVAL HOUSE ,.Clrent Needs Assessmentx »�b.. , Client Name: Last Known Address: Home Phone: Email: Names and ages of other Adults in Household: Names and ages of all Children in the home: Is client currently pregnant? Household size: Cell: Emergency Contact: (Example: Client and 2 children = 3 in household) The annual income for household is: $ See examples of documentation of income on page 3 Is client currently residing within a shelter program? If yes, what type of program? ❑ Emergency Shelter ❑ Transitional Shelter ❑ Domestic Violence Shelter ❑ Substance Abuse Treatment Program ❑ Hotel/Motel Voucher from Name of Program: Case manager: Source: ❑ Yes ❑ No Location: Contact number: Nolumes/IH Files/PROGRAMS/RENTAL ASSISTANCE/HB HOME/TBRA_2018_20_Contract/Exhibit A/Appendix/AppendixA.docx INTERVAL HOUSE Page 2 of 3 HAS CLIENT RECEIVED ANY RENTAL ASSISTANCE IN THE PAST 3 YEARS? ❑ Yes ❑ No (Includes rent, utility and move -in costs) If "Yes", please indicate what agency provided assistance: Name of Agency How long did they receive assistance? Type of assistance provided (please check all that apply): ❑ Rental assistance ❑ Utility assistance ❑ Security deposit ❑ Moving cost assistance ❑ Rapid Re -housing ❑ Other TENANT SECREENING BARRIERS (mark all that apply) ❑ Evictions: how many? ❑ Poor reference from prior landlords ❑ Lack of rental history ❑ Unpaid rent or utility bills ❑ Lack of or poor credit history ❑ One or more misdemeanors ❑ Critical felony (sex crime, arson, drugs) ❑ Other felony CLIENT'S POTENTIAL TO SUSTAIN HOUSING AFTER SUBSIDY Contact Number ❑ Eviction prevention ❑ Motel voucher ❑ Employment ❑ Employability/Strong Work History ❑ Dual parent household ❑ Evidence of increased income ❑ Evidence of approval for housing subsidy (Section 8, HUD VASH) ❑ Other: /Volumes/IH Files/PROGRAMS/RENTAL ASSISTANCEMB HOME/TBRA_2018_20_Contract/ExhibitA/Appendix/AppendixA.docx �'" INTERVAL HOUSE Page 3 of 3 q n Rental Assistance Documentatiori` Needed e ,. Scan and attach the following documents. Without the following documentation, we cannot provide rental assistance. ❑ CLIENT NEEDS ASSESSMENT ❑ IDENTIFICATION FOR ADULTS: ❑ Driver's License ❑ Passport ❑ California ID ❑Green Card ❑ Other ID ❑ SOCIAL SECURITY CARDS for everyone that will be living in the apartment or home. *Not required, bring only if you have it. ❑ BIRTH CERTIFICATES for all children that will be living in the apartment or home *Required for First 5 rental assistance ONLY. Not required for other kinds of rental assistance. ❑ BANK STATEMENT for all adults (Most Recent) ❑ DOCUMENTATION OF INCOME FOR ALL ADULTS Check below if you have any of the following income documentation (i.e. two check stubs, verification of benefits within 30 days, or deposit statements): ❑ Employment ❑ Public Benefits (Calworks) ❑ Social Security (SSI) ❑ Disability (SSDI) ❑ Unemployment ❑ Alimony ❑ Child Support ❑ Veteran Benefits n Retirement ❑ Other (please specify): NO INCOME VERIFICATION? If you don't have any of the income verifications listed above, is there any other kind of income verification you have? ❑Yes ❑Vo IF YES, Attach information about it and how much the income adds up to. ❑ HOMELESS STATUS FORMS and all documentation requested on these forms. ❑ Household falls under Category 1 (homeless) AND ❑ No appropriate subsequent housing options have been identified; AND ❑ Household lacks the financial resources and support networks needed to obtain immediate housing ❑ If you were unable to collect any of the requested documentation, please explain why: /Volumes/IH Files/PROGRAMS/RENTAL ASSISTANCE/HB HOME/TBRA_2018_20_Contract/Exhibit A/Appendix/AppcndixA.docx Appendix B TBRA Application Referred B y' Household ID # Agency: ❑Court ❑Law Enforcement ❑Health Client Personal ID # INTERVAL HOUSE ❑Social Services ❑FRC: Cm 94u &Ca lam 9Dar Mma Other: Entry Date Client Intake Part 1 Contact Tel.# Type: ❑Outreach ❑Emergency ❑Trans. ❑Hotel ❑Rental Assistance Residential Move -In Date: In Permanent Housing? ❑ Y ❑ N If yes, Date of Move -In: Client Location: ❑Orange County (CoC CA-602) ❑Long Beach (CoC CA- 606) ❑LA County (CoC CA- 600) Staff Name Grant ID: Grant Start Date: Grant End Date: Approval Status: ❑Shelter/Hotel ❑LA CalWORKs ❑OC CaIWORKs ❑Approved Special Referral ❑Needs Approval Last Name Middle Name First Name Suffix Maiden Name Name Data Quality Gender Identity SS# Client ID ❑ Full Name reported ❑ Female ❑ DL/ID: # ❑ Partial Name reported ❑ Male #: ❑ None ❑ Client Does Not Know ❑ Transgender ❑ Full SSN reported ❑ Other: ❑ Client Refused _Male to Female ❑ Partial SSN reported ❑ Data Not Collected _Female to Male ❑ Client Does Not Know ❑ ID Copied & filed in chart ❑ Other ❑ Client Refused ❑ Don't know ❑ Data Not Collected ❑ Refused to ansceer Birth Date Country of Origin Ethnicity Race (Select all that apply) Language ❑ Hispanic/Latino J Asian ❑ Non-Hispanic/Non- ❑ Native Hawaiian or Other Pacific Islander Latino ❑ Black or African -American ❑ Client Does Not Know ❑ White (includes Hispanic/Latino) ❑ Full DOB reported ❑ Client Refused ❑ American Indian or Alaskan Native ❑ Approximate or Partial ❑ Data Not Collected ❑ Client Does Not Know DOB reported ❑ Client Refused ❑ Client Does Not Know ❑ Data Not Collected ❑ Client Refused ❑ Data Not Collected Contact Information Address City Zip Code: Home Phone# Work Phone# ❑ Full or partial Zip Code Reported ❑ Client Does Not Know ❑ Client Refused Residence Prior to Program Entry: How Ion has client lived there? ❑ Emergency shelter, including hotel or motel paid for with emergency shelter voucher ❑ One day or less ❑ Transitional housing for homeless persons (including homeless youth) ❑Two days to one week ❑ Rental by client, no ongoing housing subsidy ❑ More than one week, but less than one ❑ Owned by client, no ongoing housing subsidy month ❑ Staying or living in a family member's room, apartment, or house ❑ One to three months ❑ Staying or living in a friend's room, apartment, or house ❑ More than 3 months, but less than 1 yr. ❑ Foster care home or foster care group home ❑ One year or longer ❑ Hospital or other non -psychiatric medical facility ❑ Client doesn't know ❑ Hotel or motel paid for without emergency shelter voucher ❑ Client refused ❑ Jail, prison or juvenile detention facility ❑ Data Not Collected ❑ Long-term care facility or nursing home ❑ Owned by client, with ongoing housing subsidy ❑ Permanent housing for formerly homeless persons (such as a CoC project; HUD legacy programs; or HOWPA PH) ❑ Place not meant for habitation (e.g., a vehicle, an abandoned building. bus/train/subway station/airport or anywhere outside) ❑ Psychiatric hospital or other psychiatric facility ❑ Rental by client, Veterans Assistance Supportive Housing Subsidy ❑ Rental by client, other (non--VASH) ongoing housing subsidy ❑ Rental by client, with GPD TIP subsidy ❑ Residential project or halfway house with ho homeless criteria ❑ Safe Haven ❑ Substance abuse treatment facility or detox center J Other ❑ Client doesn't know ❑ Client refused J Data Not collected Has client ever been in a shelter before? J Yes ❑ No It yes, where? when? Length of Time on Street, in an Emergency Shelter or Safe Haven ❑ Entering from the streets, shelter or Safe Haven'? ❑ Y ❑ N ❑ Client doesn't know ❑ Client refused ❑ Data Not Collected If yes, approximate Date Started Regardless of where they stayed last night —Number of times the client has been homeless on the streets, in Emergency Shelter, or Safe Haven in the past three years including today? ❑ Never in the 3 years ❑ One time ❑ Two times ❑ Three times ❑ Four or more times: Total number of months homeless on the street, in Emergency Shelter, or Safe Haven in the past 3 years: ❑ One month (this is the first month months (2-12) ❑ more than 12 months ❑ Client doesn't know ❑ Client refused Proof of homeless status collected and filed in chart: ❑ Y ❑ N Income and Sources Income received for any source ❑ Y ❑ N ❑ Client doesn't kno�� ❑ Client Refused ❑ Data Not Collected Proof of income: If yes, indicate all sources and dollar amounts for the sources that apply: ❑ Collected and Source of Monthly Cash Income: Check as many as needed filed in chart ❑ None - Employed (earned income) explain: ❑ Y ❑ N (if yes) Monthly amount $ Unemployment (Desempleo) ❑ Y ❑ N (if yes) Monthly amount $ SSI ❑ Y ❑ N (if yes) Monthly amount $ SSDI ❑ Y ❑ N (if yes) Monthly amount $ VA Service -Connected Disability Compensation ❑ Y ❑ N (if yes) Monthly amount $ VA Non -Service -Connected Disability Compensation ❑ Y ❑ N (if yes) Monthly amount $ Private Disability Insurance ❑ Y ❑ N (if yes) Monthly amount $ Workers Compensation ❑ Y ❑ N (if yes) Monthly amount $ GR (General Relief) ❑ Y ❑ N (if yes) Monthly amount $ Retirement Income from Social Security (Seguro Social) ❑ Y ❑ N (if yes) Monthly amount $ Pension or retirement income from a former job ❑ Y ❑ N (if yes) Monthly amount $ Child Support (Mantenimiento de hijos) ❑ Y ❑ N (if yes) Monthly amount $ Alimony or other spousal support ❑ Y ❑ N (if yes) Monthly amount $ Other (Otro) ❑ Y ❑ N (if yes) Monthly amount $ Ca1WORKs Cash Aid (Ayuda monetaria) ❑ Y ❑ N (if yes) Monthly amount 0 Mother & Children (Madre a hijos) monthly amount $ 0 Children only (Hi'os solamente) monthly amount $ ❑ Applying (A licando) Case # DASU/ GAIN Worker Name and Phone # Non -Cash Benefits received from any source ❑ Y ❑ N ❑ Client doesn't know ❑ Client Refused ❑ Data Not Collected Source of Monthly Non -Cash Benefits: Check as many as needed ❑ Food Stamps/SNAPS (Estampillas) $ ❑ Medi-CAL ❑ Medi-CARE ❑ State Children's Health Insurance ❑ WIC ❑ Veteran's (VA) Medical Services ❑ CaIWORKS Childcare Services ❑ CaIWORKs Transportation Services ❑ Other CalWORKS Services ❑ Section 8, public housing, or other ongoing rental assistance ❑ Other source: ❑ Temporary Rental Assistance Covered by health insurance? ❑ Y ❑ N ❑ Client Does Not Know ❑Client Refused ❑ Data Not Collected (If yes, indicate all sources that apply) ❑ Medi-CAL ❑ State Children's Health Insurance ❑ Veterans (VA) Medical Services ❑ Employer provided Health Insurance ❑ Health Insurance obtained through COBRA O Private Pay Health Insurance ❑ State Health Insurance for Adults Total Monthly Income Occupation Client Education from all sources ❑ High School Graduate ❑ _th Grade ❑ No School ❑ Some College/Vocational ElCollege Graduate ❑ Other $ /per month Marital Status Clients Relationship to Head of Household? ❑ Sim -de J Self (Head of Household) ❑ Married ❑ Head of Household's Child ❑ Divorced ❑ Head of Household's Spouse or Partner ❑ Other: ❑ Head of Household's Other Relation Member (other relation to head of household) ❑ Other: Non -relation Member Is client living with Batterer? Batterer is current or former Victim's Sexual Orientation Length of relationship ❑ Ye, ❑ Boyfriend ❑ Husband ❑ Heterosexual J Lesbian J No ❑ Girlfriend ❑ Wife ❑ Gay ❑ Bisexual ❑ Other: ❑ Other ❑ Declined to answer Does Client Have A Disabling List Health Problems Is client taking any medication? Required Medications Condition? J Yes ❑ Yes, for physical needs ❑ No ❑ Yes, for emotional needs ❑ Client Does Not Know ❑ No Is medication life- ❑ Client Refused sustaining? ❑ Data Not Collected ❑ Yes ❑ No Chronic Health Condition? (Examples of Chronic Health conditions include, but are not limited to: heart disease; severe asthma; diabetes; arthritis -related conditions; traumatic brain injury; PTSD, dementia, severe headache/migraine; cancer; chronic bronchitis; liver condition; stroke; or emphysema) ❑ No ❑ Yes ❑ Client doesn't know ❑ Client refused ❑ Data Not Collected IF YES: Expected to be of long -continued and indefinite duration and substantially impairs ability to live independently? ❑ No ❑ Yes ❑ Client doesn't know ❑ Client refused ❑ Data Not Collected Documentation of disability and severity on file? ❑ No ❑ Yes Currently receiving services/treatment for this condition? J No Cl Yes ❑ Client doesn't know O Client refused ❑ Data Not Collected HIV/AIDS ❑ No ❑ Yes ❑ Client doesn't know ❑ Client refused IF YES : Expected to substantially impair ability to live independently? ❑ No ❑ Yes ❑ Client doesn't know ❑ Client refused ❑ Data Not Collected Documentation of disability and severity on rile? ❑ No ❑ Yes Currently Receiving Services/treatment for this condition? ❑ No ❑ Yes ❑ Client doesn't know ❑ Client refused ❑ Data Not Collected Primary Physician Does Client have any disabilities? Mental Health Problem Does client have a primary physician or health Physical Disability? ❑ No ❑ Yes ❑ Client Does Not Know clinic for medical care? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client Refused ❑ Y (Si)❑ N (No) ❑ Client Refused ❑ Data Not Collected ❑ Data Not Collected IF YES Name of doctor: IT YES Expected to be of long -continued and indefinite Phone #: Expected to be of long -continued and indefinite duration duration and substantially impairs ability to live independently? and substantially impairs ability to live Name of pediatrician: ❑ No ❑ Yes ❑ Client Does Not Know independently? Phone #: ❑ Client Refused ❑ No ❑ Yes ❑ Client Does Not Know ❑ Data Not Collected ❑ Client Refused ❑ Data Not Collected Documentation of disability and severity on file? ❑ No ❑ Yes Documentation of disability and severity on Pile? ❑ No ❑ Yes Currently receiving services/treatment for this condition? Currently receiving services/treatment for ❑ No ❑ Yes ❑ Client Does Not Know this condition? ❑ Client Refused ❑ No ❑ Yes ❑ Client Does Not Know ❑ Data Not Collected ❑ Client Refused ❑ Data Not Collected Developmental Disability? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected IF YES Expected to be of long -continued and indefinite duration and substantially impairs ability to live independently? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected Documentation of disability and severity on file? ❑ No ❑ Yes Currently receiving services/treatment for this condition? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected Is Client Pregnant? Is Client a Veteran? Exercise Routine Do you exercise? Is Client Pregnant?❑ Y (Si) ❑ N (No) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Client Does Not Know ❑ Client Refused If so, how many times per week? ❑ Data Not Collected Family Composition ❑ Single Parent ❑Foster Parent(s) ❑Unaccompanied (single person) ❑Two Parents ❑Adults No Children (couple w/no kids) Children (Full Name) W/client? Birth Gender Ethnicity Does child Does child have a Date (if different) have any social security allergies? number? l . ❑ Y ❑ Y ❑ Y ❑M ❑F ❑N ❑N ❑N Covered by Health ❑ Y ❑ N ❑ Client Does Not Know ❑Client Refused Insurance? (If yes, indicate all sources that apply) ❑ Medi-CAL ❑ State Children's Health Insurance ❑ Veterans (VA) Medical Services ❑ Employer provided Health Insurance ❑ Health Insurance obtained through COBRA ❑ Private Pay Health Insurance ❑ State Health Insurance for Adults ❑Y ❑Y ❑Y El ❑F El El ❑N Covered by Health ❑ Y ❑ N ❑ Client Does Not Know ❑Client Refused Insurance? (If yes, indicate all sources that apply) ❑ Medi-CAL ❑ State Children's Health Insurance ❑ Veterans (VA) Medical Services ❑ Employer provided Health Insurance ❑ Health Insurance obtained through COBRA ❑ Private Pay Health Insurance ❑ State Health Insurance for Adults 3. ❑Y ❑Y ❑Y ❑M ❑F ❑N ❑N ❑N Covered by Health ❑ Y ❑ N ❑ Client Does Not Know ❑Client Refused Insurance? (If yes, indicate all sources that apply) ❑ Medi-CAL ❑ State Children's Health Insurance ❑ Veterans (VA) Medical Services ❑ Employer provided Health Insurance ❑ Health Insurance obtained through COBRA ❑ Private Pay Health Insurance ❑ State Health Insurance for Adults Have any of the children ever been removed from the home by court or social services? ❑ No ❑ Yes If yes, When? Notes: 4. El ❑Y ❑Y ❑M ❑F El ❑N ❑N Covered by Health ❑ Y ❑ N ❑ Client Does Not Know ❑Client Refused Insurance? (If yes, indicate all sources that apply) ❑ Medi-CAL ❑ State Children's Health Insurance ❑ Veterans (VA) Medical Services ❑ Employer provided Health Insurance ❑ Health Insurance obtained through COBRA ❑ Private Pay Health Insurance ❑ State Health Insurance for Adults Have any of the children ever been removed from the home by court or social services? ❑ No ❑ Yes If yes, When? Notes: Abuse Profile Victim of DV? Abuse Type (ALL Applicable) Weapons Used (All Applicable) ❑ Yes ❑ No ❑ Physical ❑ Gun ❑ Client Does Not Know ❑ Emotional/Mental ❑ Cut. Instrument ❑ Client Refused ❑ Sexual ❑ Blunt Obj. ❑ Data Not Collected ❑ Stalking ❑ Bodily Force ❑ Financial ❑ Other If yes, last time abused? ❑ Within the past 3 months ❑ 3 months— 6 months ago (excluding 6 months exactly) ❑ 6 months- 1 yr. ago (excluding 1 yr. exactly) ❑ One year ago or more ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected If yes, currently fleeing ❑ Yes ❑ No ❑ Client Refused ❑ Data Not Collected Substance Abuse Problem? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client refused ❑ Data Not Collected If Yes: ❑ Client ❑ Batterer ❑ Both If Client: ❑ Alcohol ❑ Drugs ❑ Both Previous drug or alcohol treatment services? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client refused ❑ Data Not Collected If yes: ❑ Residential ❑ Outpatient When? ❑ Currently ❑ Previously ❑ Client Does Not Know ❑ Client refused ❑ Data Not Collected Expected to be of long -continued and indefinite duration and substantially impairs ability to live independently? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client refused ❑ Data Not Collected Documentation of disability and severity on file? ❑ No ❑ Yes Currently receiving services/treatment for this condition? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client Refused 0 Data Not Collected Police called in the past year Restraining Order? Ilas the batterer ever been arrested for: ❑ Y 0 N Do you have a police report? ❑ Y ❑ N ❑ None ❑ Criminal ❑ Family ❑ Emergency Protective Order Domestic violence? ❑ Y ❑ N Most Recent Date Other ? Most Recent Date Emergency Contacts 11"hen an emergency situation arises, we neeLl to kn,n� who to conuut the client. I1 the clicnt has it or family that are trying to contact her, we alao nccd to know if they are an approved caller. The client should list 3 contact names and phone numbers, if applicable. The client should also list attorneys, social workers, doctors, and other important numbers. Name Phone # Relationship Approved Caller? List all attorneys, social workers, doctors, and other important numbers Name Phone # Relationship Agency Approved Caller? STATEMENT OF CONSENT I am informed and consent to receive domestic violence support services (including advocacy/ case management) through Interval House. I certify that all information provided (including income) is true and correct. Client signature: Staff signature: Date: Date: Client Intake Part 2 Do you have a safety plan? ElY ElN Left your partner before? El ❑ N Teredid you go? Reason for returning? Previous assistance through DV programs? Y (Si) ❑ N (No) When? Where? Contact person at DV program/shelter Phone #: Have you ever been arrested? ❑ Y ❑ N Offense: When: Where Legal Status (optional): ❑ US Citizen ❑ Green Card ❑Other Religious Preference (optional): Transportation What firm of transportation do you use? If you have a car: Make: Model: Year: License plate#: Do you have insurance? ❑ Y ❑ N Mental Health Treatment Ever had therapy? ❑YON Currently? ❑Y❑N When? Where? Therapist: Hospitalized? ❑ Y ❑ N When? Where? Therapist: Doctor: Ever Suicidal? ❑Y❑N Medical/Physical Treatment (Tratamineto MedicolFisico) Ever seen doctor due to abuse? 0 Y ❑ N If yes, how many times? What type of injuries? With whom? Hospitalized? ❑ Y ❑ N When? Where? Name: Gender ❑ M 0 F Date of Birth / / Legal Status ❑ US Citizen ❑ Green Card ❑Other Ethnicity: Height: Weight: Hair Color: Eyes: Age: Describe your abuser's physical appearance including any identifying marks, scars, tattoos: Occupation: Vehicle description: General Behavior" Uses alcohol? ❑ Y ❑ N What kind? How much? Uses drugs? ❑ Y ❑ N What kind? How much? How does it influence their behavior? Ever in a psychiatric hospital or treated for emotional problems? ❑ Y ❑ N Where? When? Why? Has he/she ever threatened to harm your friends, relatives, counselor, etc. for assisting you? ❑ Y ❑ N Has he/she ever acted on those threats? ❑ Y (Si) ❑ N (No) Describe: How would he/she feel if they knew you were seeking assistance from Interval House? Is he/she the father/mother of any of your children? O Y ❑ N If yes, how will he/she respond that children are with you? Appendix C Declaration of Homelessness Rental Assistance Program DECLARATION OF HOMELESSNESS STATUS Applicant Name: ❑ I certify, under penalty of perjury, that following information is true and complete: Applicant Signature: Date: Verification types: *T=Third Party / O=Observation / S=Self-certification Attach Third Party verification documentation and Intake Observation statements in back packet of folder Req form — I- B HOME' Verification Type T/O/S* Situation 1 ❑ An individual or family who lacks a fixed, regular, and adequate nighttime residence AND Check one of the following: ❑ An individual or family with a primary nighttime residence that is a public or private place not designed for or T-not required for ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, emergency bus or train station, airport, or camping ground shelter or street outreach ❑ An individual or family living in a supervised publicly or privately operated shelter designated to provide temporary living arrangements (including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state, or local government programs for low-income individuals ❑ An individual who is exiting an institution where he or she resided for 90 days or less AND who resided in an 0-not allowed emergency shelter or place not meant for human habitation immediately before entering that institution Verification Type T/O/S* Situation 2 ❑ An individual or family who will imminently lose their primary nighttime residence, provided that: The primary nighttime residence will be lost within 14 days of the date of application for homeless assistance AND No subsequent residence has been identified AND The individual or family lacks the resources or support networks, e.g., family, friends, faith -based or other social networks, needed to obtain other permanent housing Verification Type T/O/S* Situation 3 ❑ Unaccompanied youth under 25 years of age, or families with children and youth, who do not otherwise qualify as homeless under this definition, but who qualifies as "homeless" under another federal statute AND Only T is allowed have not had a lease, ownership interest, or occupancy agreement in permanent housing at any time during the 60 O is not allowed days immediately preceding the date of application for homeless assistance AND have experienced persistent instability as measured by two moves or more during the 60-day period immediately O is not allowed preceding the date of applying for homeless assistance AND can be expected to continue in such status for an extended period of time because of chronic disabilities, chronic S is not allowed physical health or mental health conditions, substance addiction, histories of domestic violence or childhood abuse O is not allowed (including neglect), the presence of a child or youth with a disability, OR two or more barriers to employment, for barriers to which include the lack of a high school degree or General Education Development (GED), illiteracy, low English employment proficiency, a history of incarceration or detention for criminal activity, and a history of unstable employment; Safety should never be put at risk in order to obtain documentation under this situation. If the provider is a DV provider self- Verification Type certification sufficient. For non -DV providers, if there is no threat of safety supporting verification should be provided. T/O/S* Situation 4- 171 Any individual or family who Is fleeing, or is attempting to flee, domestic violence, dating violence, sexual assault, stalking, or other dangerous or life -threatening conditions that relate to violence against the individual or a family member, including a child, that has either taken place within the individual's or family's primary nighttime residence or has made the individual or family afraid to return to their primary nighttime residence AND has no other residence AND lacks the resources or support networks, e.g., family, friends, faith -based or other social networks, to obtain other permanent housing Rental Assistance Program DECLARATION OF HOMELESSNESS STATUS (continued) Applicant Name: Staff Certification Req form — HB HOME I understand that third -party verification is the preferred method of certifying homelessness or risk for homelessness for an individual who is applying for assistance. I understand self -declaration is only permitted when I have attempted to but cannot obtain third party verification. Describe in detail efforts made for Third Party verification and attach documentation behind this form (email, phone logs, etc.) For clients in Situation 4 (Domestic violence), safety should never be put at risk in order to obtain documentation. If the provider is a DV provider, self -certification is sufficient. You can state that you did not obtain third -party documentation because it would have put client's safety at risk. (See instruction sheet for examples of what to write here if you are unable to obtain third -party documentation.) Staff Signature: Date: Appendix D HQS Inspection Checklist Inspection Checklist U.S. Department of Housing OMB Approval No. 2577-0169 and Urban Development (Exp. 04/30/2018) Housing Choice Voucher Program Office of Public and Indian Housing Public reporting burden for this collection of information is estimated to average 0.50 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number Assurances of confidentiality are not provided under this collection. This collection of information is authorized under Section 8 of the U.S. Housing Act of 1937 (42 U.S.C. 1437f). The information is used to determine if a unit meets the housing quality standards of the section 8 rental assistance program. Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to collect the information required on this form by Section 8 of the U.S. Housing Act of 1937 (42 U.S.C. 1437f). Collection of the name and address of both family and the owner is mandatory. The information is used to determine if a unit meets the housing quality standards of the Section 8 rental assistance program. HUD may disclose this information to Federal, State and local agencies when relevant to civil, criminal, or regulatory investigations and prosecutions. It will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Failure to provide any of the information may result in delay or rejection of family participation. Name of Family Tenant ID Number Date of Request (mm/dd/yyyy) Inspector Neighborhood/Census Tract Date of Inspection (mm/dd/yyyy) Type of Inspection Date of Last Inspection (mm/dd/yyyy) PHA Initial ❑ Special Reinspection ❑ A. General Information Inspected Unit Year Constructed (yyyy) 0 Housing. Type (check as appropriate: Single Family Detached Full Address (including Street, City, County, State, Zip) Duplex or Two Family 0 Row House or Town House 0 Low Rise: 3, 4 Stories, Including Garden Apartment Number of Children in Family Under 6 0 High Rise; 5 or More Stories 0 Manufactured Home Congregate Cooperative Owner 0 Name of Owner or Agent Authorized to Lease Unit Inspected Phone Number 0 Independent Group Q Residence Single Room Occupancy Address of Owner or Agent 0 Shared Housing 0 Other B. Summary Decision On Unit (To be completed after form has been filled out Pass Number of Bedrooms for Purposes Number of Sleeping Rooms Fail of the FMR or Payment Standard Inconclusive Inspection Checklist !an No. 1. Living Room Yes Pass No Fail In- Conc. Comment Final Approval Date (mm/dd/yyyy) 1.1 Living Room Present 1.2 Electricity 1.3 Electrical Hazards 1.4 Security 1.5 Window Condition 1.6 Ceiling Condition 1.7 Wall Condition 1.8 Floor Condition Previous editions are obsolete Page 1 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 Reg farm - HB HOME Room Codes: 1 = Bedroom or Any Other Room Used for Sleeping (regardless of type of room), 2 = Dining Room or Dining Area; 3 = Second Living Room, Family Room, Den, Playroom, TV Room, 4 = Entrance Halls, Corridors, Halls, Staircases, 5 = Additional Bathroom, 6 = Other Item 1. Living Room (Continued) No. Yes Pas No Fail In- Conc. Comment Final Approval Date mm/dd/ 1.9 Lead -Based Paint Not Applicable Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? 2. Kitchen 2.1 Kitchen Area Present 2.2 Electricity 2.3 Electrical Hazards 2.4 Security 2.5 Window Condition 2.6 Ceiling Condition 2.7 Wall Condition 2.8 Floor Condition 2.9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Not Applicable 2.10 Stove or Range with Oven 2.11 Refrigerator 2.12 Sink 2.13 Space for Storage, Preparation, and Serving of Food 3. Bathroom 3.1 Bathroom Present 3.2 Electricity 3.3 Electrical Hazards 3.4 Security 3.5 Window Condition 3.6 Ceiling Condition 3.7 Wall Condition 3.8 Floor Condition 3,9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Not Applicable 3.10 Flush Toilet in Enclosed Room in Unit 3.11 Fixed Wash Basin or Lavatory in Unit 3.12 Tub or Shower in Unit 3.13 Ventilation Previous editions are obsolete Page 2 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 Req form - HB HOME Item No. 4. Other Rooms Used For Living and Halls Yes i No 1 In- Final Approval Pass F Conc. v Comment Date (TjVddlyyyy) -- 4.1 Room Code` and (Circle One) (Circle One) Room Location Right/Center/Left Front/Center/Rear Floor Level 4.2 Electncit /Illumination --� 4.3 Electrical Hazards 4.5 vvinaow uonamon 4 6 Ceilino Condition 4./ vvain L onamon 4.8 Floor Condition _....-.................................. _ _ 4.9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 4.1 Room Code' and (Circle One) (Circle One) Room Location ❑ RightlCenter/Left Front/Center/Rear _Floor Level __......_..._..._._ ____._._._...__.._.. 4.2 Electricity/Illumination _.............. .... _...... _...._...._......................_...._..___._._..___-___ _______................. _ 4.3 Electrical Hazards 4.4 Security 4.5 Window Condition 4.6 Ceiling Condition 4.7 Wall Condition 4.8 Floor Condition 4.9 Lead -Based Paint ❑ Not Applicable Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? 4.10 Smoke Detectors 4.1 Room Code' and j (Circle One) (Circle One) Room Location u Right/Center/Left Front/Center/Rear _Floor Level 4.2 Electricity/Illumination 4.3 Electrical Hazards 4.4 Security 4.5 Window Condition 4.6 Ceiling Condition 4.7 Wall Condition i I 4.8 Floor Condition 4.9 Lead -Based Paint ❑ Not Applicable Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Previous editions are obsolete Page 3 of 8 form HUD-52580 (4/2015) ref Handbook 7420 8 Req form - HB HOME Item 4. Other Rooms Used For Living and Halls Yes No. Pass No Fail In- Conc. Final Approval Comment Date (mm/ddlyyyy) 4.1 Room Code ' and Room Location (Circle One) (Circle One) Right/Center/Left Front/Center/Rear Floor Level 4.2 Electricity/Illumination 4.3 Electrical Hazards 4.4 Security 4.5 Window Condition 4.6 Ceiling Condition 4.7 Wall Condition 4.8 Floor Condition 4.9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Not Applicable 4.10 Smoke Detectors 4.1 Room Code' and (Circle One) (Circle One) Room Location Right/Center/Left Front/Center/Rear Floor Level 4.2 Electricity/Illumination 4.3 Electrical Hazards 4.4 Security 4.5 Window Condition 4.6 Ceiling Condition 4.7 Wall Condition 4.8 Floor Condition 4.9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Not Applicable 4.10 Smoke Detectors 5. All Secondary Rooms (Rooms not used for living) 5.1 None Go to Part 6 5.2 Security 5.3 Electrical Hazards 5.4 Other Potentially Hazardous Features in these Rooms Previous editions are obsolete Page 4 of 8 form HUD- 52580 (4/2015) ref Handbook 7420.8 Req form - HB HOME Item 6. Building Exterior No. yes No , Pas Fail In- anc. +. Final Approval Comment Date (mm/dd/yyyy) 6.1 Condition of Foundation 6.2 Condition of Stairs, Rails, and Porches 6.3 Condition of Roof/Gutters 6.4 Condition of Exterior Surfaces 6.5 Condition of Chimney 6.6 Lead Paint: Exterior Surfaces Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed 20 square feet of total exterior surface area? Not Applicable 6 7 Manufactured Home: Tie Downs 7. Heating and Plumbing 7.1 Adequacy of Heating Equipment 7.2 Safety of Heating Equipment 7.3 Ventilation/Cooling 7.4 Water Heater 7.5 Approvable Water Supply 7.6 Plumbing 7.7 Sewer Connection 8. General Health and Safety 8.1 Access to Unit 8.2 Fire Exits 8.3 Evidence of Infestation 8.4 Garbage and Debris 8.5 Refuse Disposal 8.6 Interior Stairs and Commom Halls 8.7 Other Interior Hazards 8.8 Elevators 89 Interior Air Quality 8.10 Site and Neighborhood Conditions 8.11 Lead -Based Paint: Owner's Certification Not Applicable If the owner is required to correct any lead -based paint hazards at the property including deteriorated paint or other hazards identified by a visual assessor. a certified lead -based paint risk assessor, or certified lead -based paint inspector, the PHA must obtain certification that the work has been done in accordance with all applicable requirements of 24 CFR Part 35. The Lead -Based Paint Owner Certification must be received by the PHA before the execution of the HAP contract or within the time period stated by the PHA in the owner HQS violation notice. Receipt of the completed and signed Lead -Based Paint Owner Certification signifies that all HQS lead -based paint requirements have been met and no re -inspection by the HQS inspector is required. Previous editions are obsolete Page 5 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 Req form - HB HOME C. Special Amenities (Optional) This Section is for optional use of the HA. It is designed to collect additional information about other positive features of the unit that may be present. Although the features listed below are not included in the Housing Quality Standards, the tenant and HA may wish to take them into consideration in decisions about renting the unit and the reasonableness of the rent. Check/list any positive features found in relation to the unit. Living Room High quality floors or wall coverings Working fireplace or stove Balcony, patio, deck, porch Special windows or doors Exceptional size relative to needs of family Other: (Specify) 2. Kitchen Dishwasher Separate freezer Garbage disposal — Eating counter/breakfast nook Pantry or abundant shelving or cabinets Double oven/self cleaning oven, microwave Double sink — High quality cabinets — Abundant counter -top space Modern appliance(s) — Exceptional size relative to needs of family Other: (Specify) 3. Other Rooms Used for Living n High quality floors or wall coverings #uy Working fireplace or stove Balcony, patio, deck, porch Special windows or doors Exceptional size relative to needs of family Other (Specify) 4. Bath Special feature shower head Built-in heat lamp Large mirrors Glass door on shower/tub Separate dressing room Double sink or special lavatory -I Exceptional size relative to needs of family Other: (Specify) 5. Overall Characteristics Storm windows and doors Other forms of weatherization (e.g., insulation, weather stripping) Screen doors or windows Good upkeep of grounds (i.e., site cleanliness, landscaping, condition of lawn) Garage or parking facilities Driveway Large yard Good maintenance of building exterior Other. (Specify) 6. Disabled Accessibility Unit is accessible to a particular disability. ❑ Yes ❑ No Disability Previous editions are obsolete Page 6 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 Req form I— HB HOME 1. Does the owner make repairs when asked? Yes 1:1No 2. How many people live there? 3. How much money do you pay to the owner/agent for rent? $ 4. Do you pay for anything else? (specify) _ 5. Who owns the range and refrigerator? (insert O = Owner or T = Tenant) Range 6. Is there anything else you want to tell us? (specify) Yes ❑ No ❑ Refrigerator __ Microwave❑ Previcus edit ors a,e ccsclete Page 7 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 E. Inspection Summary/Comments (Optional) Provide a summary description of each item which resulted in a ratin of "Fail' or "Pass with Comments." Tenant ID Number i Inspector Date of Inspection (mm/dd/yyyy) Address of Inspected Unit Type of Inspection Initial Special Reinspection Item Number Reason for "Fail' or "Pass with Comments" Rating Continued on additional page Yes 1:1No Previous editions are obsolete Page 8 of 8 form HUD-52580 (4/2015) ref Handbo 7420 8 Appendix E Landlord Agreement INTERVAL HOUSE G_&hk-8[�_1.A—.1D—r. Regform_=?1 "FC3 I LANDLORD - INTERVAL HOUSE RENTAL ASSISTANCE AGREEMENT To: (Landlord, Property Manager or Property Owner Name): On Behalf of: (Participant name): Address of Rental Property: Date: Dear Landlord: We are very pleased to inform you that (Participant name) has been approved for short -/medium -term rental assistance through the City of Huntington Beach. Through this Rental Assistance program, Interval House will make rental payments as a contractor of the City of Huntington Beach. Payments will be made directly to (Landlord, Property Manager or Property Owner name), on behalf of (Participant name), using a corporate check or money order. The payment will be mailed or hand delivered by Interval House staff to (Landlord, Property Manager or Property Owner name)'s address noted at the bottom. If at any time during the term of this agreement the tenant is given a notice to vacate the housing unit, or any complaint used under state or local law to commence an eviction action against (Participant name), (Landlord, Property Manager or Property Owner) shall also provide copy of said notice to Interval House at the address noted at the bottom. Interval House will make timely payments to (Landlord, Property Manager or Property Owner name) in accordance with the tenant rental agreement information below: Payment Due Date: Grace Period: Late Payment Requirements: Interval House will provide rental assistance in the following amount: S Security Deposit (not to exceed two months' rent) S Rental for month of This contribution will be reassessed on a monthly basis and may be subject to change depending on the client's level of need and other circumstances. The amount above may represent the entire or partial amount of the month's rent and (Participant name) shall be responsible for any balance due. In the case that any late fees or penalties are incurred, they are the responsibility of (Participant name). The term of this contract begins on the first day of the term of the lease. If a lease is terminated due to lease term violation, our assistance will end at time of termination. By signing this agreement, the landlord commits to complying with the tenant protections in 24 CFR §92.253. Please see the attached Tenant Protection Agreement for more information. Interval House is a nationally recognized award -winning non-profit organization offering housing and comprehensive support services to families in Los Angeles and Orange Counties since 1979. Interval House works closely with many cities and agencies to provide housing assistance for our local communities. We are proud to be able to offer housing subsidy programs for eligible and worthy individuals. Your prospective tenant has been approved for our housing subsidy. Please feel free to contact us with any questions or for any additional information at the phone number listed below. Both Interval House and (Landlord, Property Manager or Property Owner Name) agree to the terms noted above. Please sign below: Signature Print Name Interval House P.O. Box 3356 Seal Beach, CA 90740 Phone: (562) 594-9492 admin@intervalhouse.org Signature Print Name (Landlord, Property Manager or Property Owner Name): Address Line 1 Address Line 2 Phone/Fax # Email Address Appendix F Tenant Protection Agreement INTERVAL HOUSE C,-Sh.h.8 C.-b.Yka.d Da YMmu TENANT PROTECTION AGREEMENT (attach to lease) Dear Landlord: d'q"for ry: i a? F' 1 i'fl ; E We are very pleased to be working with you to provide short -/medium -term rental assistance to (participant name). We would like to inform you of some important tenant protections required by the city of Huntington Beach. We recognize that these terms are unlikely to be in your lease. However, we must ensure you understand that we are unable to support a lease that includes such terms. The written lease between yourself and the tenant may not contain any of the following provisions: (1) Agreement to be sired. Agreement by the tenant to be sued, to admit guilt, or to a judgment in favor of the owner in a lawsuit brought in connection with the lease; (2) Treatment oj'property. Agreement by the tenant that the owner may take, hold, or sell personal property of household members without notice to the tenant and a court decision on the rights of the parties. This prohibition, however, does not apply to an agreement by the tenant concerning disposition of personal property remaining in the housing unit after the tenant has moved out of the unit. The owner may dispose of this personal property in accordance with State law; (3) Excusing owner ftom responsibility. Agreement by the tenant not to hold the owner or the owner's agents legally responsible for any action or failure to act, whether intentional or negligent; (4) Waiver of notice. Agreement of the tenant that the owner may institute a lawsuit without notice to the tenant; (5) Waiver of legal proceedings. Agreement by the tenant that the owner may evict the tenant or household members without instituting a civil court proceeding in which the tenant has the opportunity to present a defense, or before a court decision on the rights of the parties; (6) Waiver of a jury trial. Agreement by the tenant to waive any right to a trial by jury; (7) Waiver of right to appeal court decision. Agreement by the tenant to waive the tenant's right to appeal, or to otherwise challenge in court, a court decision in connection with the lease; (8) Tenant chargeable with cost of legal actions regardless of outcome. Agreement by the tenant to pay attorney's fees or other legal costs even if the tenant wins in a court proceeding by the owner against the tenant. The tenant, however, may be obligated to pay costs if the tenant loses; and (9) rldandatory supportive services. Agreement by the tenant (other than a tenant in transitional housing) to accept supportive services that are offered. Furthermore, by signing this agreement you recognize your obligation to maintain the Housing Unit in accordance with the Housing Quality Standards established at 24 CFR 982.401, and to refrain from discriminating against the tenant's household. Please sign below as agreement to these terms: Signature Print Name Appendix G Rent Reasonableness Req.,,info/;,not req,.°:foam-= HB`HOME RENTAL ASSISTANCE RENT REASONABLENESS CERTIFICATION Proposed Unit Unit #1 Unit #2 Address Number of Bedrooms Square Feet Type of Unit/Construction Housing Condition/Quality Location/Accessibility Amenities Unit: Site: Neighborhood: Age in Years Utilities (type) Unit Rent Utility Allowance Gross Rent Handicap Accessible? CERTIFICATION: A. Rent Two comparable units must be identified in order to certify Rent Reasonableness. Find listings for comparable units online (on Craigslist or a similar site). ** Print out the listings and attach them in back pocket of folder as proof. Proposed Contract Rent + Utility Allowance = Proposed Gross Rent (from utility allowance spreadsheet on next page) B. Compliance with Rent Reasonableness Rent ❑ is ❑ is not reasonable in comparison to rent for other comparable unassisted units. (to be reasonable, the rent must not exceed the rent of comparable units) Staff Name: Staff Signature: Date: Appendix H Utility Allowance Req info 1 not req fo"Ih'�for:,,VVVV(-:F :B% :C HUCIfHB HIJ II.E _ex�xy 3 Community'lResources 2018 Utility Allowances for Housing Choice Voucher Program The following Utility Allowances will be used by the Orange County Housing Authority (OCHA) for administration of the Housing Choice Voucher Program effective November 1, 2017. Bedroom 1 0 1 1 1 2 1 3 1 4 1 5+ Gas Cooking 2 3 1 4 5 1 6 8 Heating 11 13 15 16 1 17 19 Water Heating 6 7 10 14 18 22 a �,,.r. tectric Basic 20 23 33 46 59 73 Cooking 4 5 9 13 17 20 Heating 15 18 20 22 24 28 Water Heatin 11 15 22 27 32 37 Other Water 31 32 1 44 1 63 1 81 1 100 Trash/Sewer 26 Refrigerator 9 Stove 7 Orangee Coun-sh-I HousIng AuthoriW 1 770 N. BROADWAY, SANTA ANA CA. 92706 0 PHONE (714) 480-2700 FAX (714) 480-2945 Appendix I Participant Agreement Agreement between Req'y form HB HOME Interval House Rental Assistance/Participation Agreement (participant name) and Interval House The Interval House Rental Assistance program aims to provide homeless and low-income households at extremely high risk of homelessness with financial assistance accompanied by supportive services to rapidly secure housing. You have been approved for initial financial assistance for a period of months in the amount of: Initial 6-month period: This contribution will be reassessed after 6 months Your total rent: $ and may be subject to change depending on the client's level of need and other circumstanecs. Interval House contribution: $ Client contribution: $ (from Calculation of Client Contribution form) I understand that receipt of this assistance is contingent upon my agreeing to and complying with the programs requirements outlined below. I further understand that financial assistance has been approved for a period of months. In order for additional financial assistance to be approved I must be reassessed for continued eligibility at the end of this time period. I agree to the following: • Provide accurate and honest information to my case manager or other agency staff. • Meet with my case manager at intervals established in my housing and service plan. • Work collaboratively with my case manager to establish a housing and service plan and take necessary steps to achieve the goals outlined in this plan. • Provide current proof of income for reassessment meetings. • Pay my portion of the rent on time every month and immediately advise my case manager if I have any trouble doing so. • Provide any documentation required by my case manager as it pertains to my services plan, rent or income (i.e. attendance record for job training, proof of debt payments, etc.) • Sign a release of information so that my case manager can collaborate with any other service providers that I'm working with. • Have a written lease for my apartment with a legitimate landlord. I may not sublet my unit or have anyone not already approved staying there for an extended period of time without the program approval. I must comply with all the requirements of my lease. • Agree to be responsible for my rent on my own after the rental assistance ends. • Agree to be contacted for follow-up calls after I complete the program. My signature represents that I understand what is expected of me by the Interval House Rental Assistance Program. I also agree to cooperate with my individual housing and services plan. I understand that the sponsoring agency is not responsible for my rent or lease. Financial assistance will only be paid on my behalf if I am in full compliance with the program requirements. Print Client Name: Client Signature: Date: Print Staff Name: Staff Signature: Date: Appendix J Case Management and Self Sufficiency Program Policies and Procedures INTERVAL HOUSE Crisis Shelters & Centers forVidims of Domestic Violence Interval House utilizes a client -centered, trauma informed approach for our self-sufficiency - case management program. Key staff and specialists, who will be working with the household, participate in the Assessment/Goal Tracking Sheet interview in a team approach so that the client will only need to share their story once. This also enables specialized staff to further assess the client's needs and goals. We work hand in hand with the client to empower them and help them to determine the steps needed to successfully reach their goals. Interval House has developed the Individualized Service Plan/Goal Worksheet as a guide and checklist for our Self -Sufficiency program from entry to exit. These forms outline the comprehensive assessments and services that are offered to rental assistance clients and their children throughout their program at Interval House. The following services are offered as part of the Self- Sufficiency Case Management program: 1. Individualized Housing and Service Plan 2. Housing Search and Placement 3. Legal Services 4. Financial Management/Credit Repair 5. Employment Assistance 6. Transportation 7. Counseling dft Sec#ion 2: /�. s •.t Y ♦. � p. .x 4 . �t Y . The Interval House Case Management model maximizes client success by developing individualized service plans and addressing clients' specific needs in securing permanent housing and self-sufficiency. Each participant will also develop an individualized Service Plan with their Case Manager addressing specific goals and time frames for short-term and long-term goals. Individualized services and resources are planned to meet the unique needs of rental assistance participants. Case Managers will monitor client's progress on a regular basis (at minimum monthly) and make revisions as needed with the participant. The service plan components include: • Housing • Interpersonal/emotional • Medical • Legal • Financial • Educational & vocational •And other immediate needs (such as transportation, clothing, food, etc.). All clients deserve devoted housing advocate case managers who are sensitive to their needs and who meets regularly with each client for ongoing support. Case managers will coordinate the delivery of all supportive services needed, working closely with clients and local community resources. q r:. Attaining safe, permanent housing is a primary goal for all Interval House rental assistance participants. Housing search, placement, and establishment activities are planned in detail from the clients' intake assessment. Housing Advocates will work closely with clients to design carefully planned steps and activities in researching neighborhoods, negotiating leases, and advocating tenants' rights. Families are given the choice for selecting their housing and some may transition sooner and some take longer for their preferred housing options. For over 36 years, Interval House has worked closely with local Apartment Association and Housing networks to secure and strengthen relationships with landlords and property owners on behalf of homeless families. Interval House also maintains strong working relationships with building industry and private housing executives to strengthen housing inventory in Orange County. Landlords are provided with the incentive that Interval House has properly screened the family and will continue to provide support services as long as needed to the family to ensure housing stability and self-sufficiency. Interval House regularly follows up with landlords and monitors clients to see if any needs have been identified that would benefit from program advocacy. Interval House's maintains operational agreements with private landlords/owners and permanent housing providers for first option of over 40 units, and linkages to hundreds of vacancies as the adopted charity partner for the Apartment Association, Southern CA cities. yr. r •f f J 1 k, Staff attorneys, legal advocates and volunteer attorneys provide comprehensive legal services and representation in multiple languages. Legal assistance includes lease agreements, legal advocacy, court accompaniment, and other legal issues affecting homeless and at -risk homeless persons and their children. Interval House legal advocates provide legal assistance through individual legal counseling sessions, group legal clinics, court accompaniment and representation, and legal advocacy. Staff are trained to fully understand and explain relevant laws to clients and to help "walk them through" the relevant legal systems. a C� Obtaining financial self-sufficiency is a critical goal for households served by Interval House. Financial Empowerment support includes: setting individual financial goals and timelines; developing, implementing, and monitoring a financial plan; increasing financial income; active budgeting and savings; repairing/improving credit; and reducing debt. A unique component is our award -winning financial management program, provided in partnership with the Financial Planning Association and its volunteer financial advisors. A partnership with nationally recognized financial expert Suze Orman provides all participants with financial tool kits, which assists clients with credit repair, financial literacy, and job placement and retention. Interval House has designed an 8-week comprehensive financial empowerment curriculum with weekly workshops conducted to assist program participants with credit repair, financial literacy, and job placement and retention. Assistance will also be provided to access mainstream financial benefits including social security, veteran's benefits, CalWORKs, disability, unemployment, and other public assistance. Obtaining self-sufficiency is a critical goal for families served by Interval House. Interval House Case Managers work with clients to identify interests, life experiences and talents that lend themselves to employment. Housing Advocates also: 0 Help clients develop resumes, complete job application and prepare for interviews; a Obtain educational scholarships through AmeriCorps and other sources to increase leadership skills and/or further their education; Provide transportation solutions to job interviews and job -related activities; and ■ Provide job placement in career -level jobs and job retention assistance. Interval House provides support services at our Community Service Center and Satellite sites in Huntington Beach conveniently accessible via public transportation routes or via home visits as needed. Interval House provides assistance with transportation via bus passes and accessing mainstream resources available for transportation through CaIWORKs and disability access. Interval House also maintains agreements with local taxi companies to provide emergency transportation assistance and works closely with the Huntington Beach Police Department to assist transport participants in crisis situations. 14W Interval House provides an array of individual and group counseling programs on -site and works closely with other mental health providers to address behavioral health needs of participants. Sensitive and flexible counseling services will be available from peer support to therapeutic individual and group counseling provided by skilled professional and paraprofessional counselors in over 70 different languages. Interval House Individualized Service Plan Goal Worksheet Client Name: Children Name/Age: Instructions for this Goal Workshecet: • Goal setting is a VOLUNTARY support service forour participants. • Any Goals listed here should bel[iO% dictated by the Survivor. Staffs rule k to provide support as Survivors determine. their own goals. • We encourage staff to write clown the goals that Survivors want: to accomplish starting on the Phone Intake and do a draft before client conses. • Finalize based on Survivor's plans expressed to staff during in -person intake. • Staff should offer support to Survivor to make any updates Weekly for shelter & Monthly for rental assistance • Offer copy to client after EVERY update. Explain the Following to Client Rehire Beginning: • The staff here want to offer any support and information you may need to accomplish any immediate goals or longer term goals that you decide is best for you. If you would like, we can help put together a written plan based on what you want to do while you are tvith us. • You can write down any updates to your goals and we will offer to help you edit this goal worksheet on a regular- basis and offer you a coley. • Whether ill' not you Use this tool or accomplish goal,, that you put down, your participation in our program evill not be affected. • This is only a guide to help organize your goals, if you choose to use it. • Please know if you have a support person with you or waiting for you, you are welcome to Invite them in for any part of this process. Intake Date: Initial Goal Worksheet Completed: with: (Elate) (names of client & ALL staff involved) Lest Updated Date: STAFF SUPPORT: Client Advocate/Counselor: Children: Financial/CaIWORKs: Legal: Other (we are ALL here to help): *Addit'ional advocateslstaff'can assist with spt cifrc go alslsteps as you determine. 21t118 20 (Esnmwl F\hibil 1 1i,1,; . El€.ti•':!�:-j�L'llii€h C.ClEtc HOUSING Goals Person/s Responsible Steps needed to reach goal & any Goals Achieved/Outcomes assistance needed (Were goals obtained?) List ALL Mousing goals determined by Participant: For example: Achieving the,e goals determined by • Look fur housing in area participant is NOT required and For example: - Cet fiertrinrre Drat rv/'prE•r�iarrs home1 voluntaryTracking of eoals by • .11n+,c� into mrra Aperrtruc�rta • Complete housing applications aparticipant optional. �rtic� ant is o • li/love into Transitional Mousing � Take care of past rent owed • Find Room to Rent for E,diron low-income utility program • Look into Hortsirt,� AssistanceApply (if eligible) Available (if gwdlified) • 0 T11' R • OTHER: ---------- • Not Applicable 1. ❑Yes ❑ In Progress ❑Yes ❑ In Progress 2. ❑Yes ❑ in Progress 3. ❑Yes ❑ In Progress 4. /Volumes/ill FilesiP.R.OGRAMS/R.FNTAL ASSISTANCEIHB.HOMEiTBRA_2018_20_Contraet/Fxhibit A; AppendixlAppendixJ2.doc FINANCIAL,/INCOME Goals Person/s Responsible Steps needed to reach goal & any Goals Achieved/Outcomes assistance needed (Were goals obtained?) Describe ALL Financial goals determined by Participant: For e v"t771 thl e Achieving these nails determined by • Go to 1_ crlll'(_)1ZK.r f>/%tCL' /Onr[rl'r"O la' tit StunFor participant is NO required and voluntary. evarrrple: • .S°tixrr Job or7twation rail date Tracking of goals, by paIticipantis « Get on CaIIVORA's _ . a p/,�15> frrr rurernJ�Tnynrent a)t(onal. i • a Stunt Job• Start • Cont(n r Child i'rrpport glfice fbr Child Support • Develop (1 rnonthly budget to help keep track of • Ger on Uncnrpim,nrem • save $ per Month ea�rerr.ces • Develop an emergency srnviu;"s plan OTHER: . OTHER: • Not Applicable Current Monthly Income: Started new job. Source of Income: ❑Yes ❑ In Progress 1. Dyes ❑ In Progress 2. Increase Financial Education & Client would like to participate in (check all that apply): Knowledge by working with the Interval House Financial ❑ Introduction to Banking Empowerment Program ❑ Introduction to Credit & Reviewing Credit Report ❑ Choosing & Keeping Checking Account ❑ Budgeting & Tracking Your Money ❑ Why You Should Save, Save, Save ❑ Consumer Rights ❑ How Credit History Affects Your Credit Future ❑ How to Make a Credit Card Work for You ❑Yes ❑ In Progress 3. /Volumes/IH Files.`PROGRAMS.'RENTAL ASSISTANCE/HB HOME:'TBRA_2018_20_Contract/Exhibit AjAppendixiAppendixJ2.doc EDUCATIONAL Goals Person/s Responsible Steps needed to reach goal & any Goals Achieved/Outcomes assistance needed (Were goals obtained?) Describe ALL Educational goals determined by Participant' (or ttCCln7lalc: lcl iev in,,ibese goals determined by + .Sign classes cart elate p nlicip int is NOT regtured and volunttlry_ For elvanrple: �� _ • Sign crp far• Futnrreinf 1rcl 1 nicking of goals by participant is optional. • Sinn School far pro,�7rwn • Apph- fi'w .w hoof e_spc nSNs i4 ilh j'Ve( iwe /o VVork • Finish Degree [II _ Scllool social worker + Enroll in ESL Classes . 0171ER: • Obtain a C ,rtitieate in _ Get a GED * OTHER: -- — • Not Applicable What is the Highest Education Level You have Completed? I. ❑Yes ❑ In Progress ❑Yes ❑ In Progress 2. ❑Yes ❑ In Progress 3. /Volumes;IH Files/pR.OGR.AMYRENTAL ASSISTANCE/HB HOME.ITBRA_2018_20 Contract%Exhibit A'AppendixrAppendixJ2.doc EMPLOYMENT Goals Person/s Responsible Steps needed to reach goal & any Goals Achieved/Outcomes assistance needed (Were goats obtained?) Describe ALL Employment goals determined by Participant: Achieving thesegoals determined by Participant is NOT required and voluntary. For example: Tracking of ,goals by participant is • Get a Job optional. • Start Jnh Search • Transfer Job Location due Io Saff,t1� • OTHER: • Not Applicable • Are you currently working? NO YES if yes, WHERE Past Work Experience: Dyes ❑ In Progress 1. ❑Yes ❑ In Progress 2. Improve Job Readiness Skills by Client would like to participate in (check all that apply): working with the Interval House Employment Program ❑ Employment Assessment ❑ Writing a Resume ❑ Cover Letters and Job Applications ❑ Preparing for Interviews ❑ Job Search ❑ Business Etiquette Eyes ❑ In Progress 3. /Volumes/.IH .Files/PR.OGRAMS/R.F.,NTAL ASSISTANCEJHB HOME/TBRA_2018_20_Contract/Exhibit A/Appendix/AppendixJ2.doe LEGAL Goals Person/s Responsible Steps needed to reach goal & any Goals Achieved/Outcomes assistance needed (Were goals obtained?) Describe ALL Legal goals determined by Participant: For example: Achieving these goals determined by • Complete legal letter requert participant is NOT required and voluntary. For example: Tracking of goals by participant is optional. • Get a Restraining Order • Take care ol'past Legal Issues • Get legal assistance an • Learn about Tenaw fthts • OTHER: • Not Applicable 1. Dyes ❑ In Progress ❑Yes ❑ In Progress 2. HEALTH & WELLNESS Goals Person/s Responsible Steps needed to reach goal & any Goals Achieved/Outcomes assistance needed (Were goals obtained?) Describe ALL Health & Wellness goals determined by Participant: Achieving these goals determined by For example: participant is NOT required and voluntary. • Seek medical atteruiau on Tracking of` goals by participant is optional, • Get 7*13 Tess Dane (ftw shelter cliews) • Get Health hisurance • 07 HGR: _ ����--- • Not Applicuble Do you have health insurance? NO YES If yes, WHAT KIND 1. Dyes ❑ In Progress /Volumes.41-1 Files:'PR.OGRAMS:RENTAL ASSISTANCE;HB H0ME/TBRA_2018_20 Contract-Exbibit A: Appendix/AppendiaJ2.doe CHILDREN'S Goals Person/s Responsible Steps needed to reach goal & any Goals Achieved/Outcomes assistance needed (Were goals obtained?) Describe ALL Cliddren's goals determined by Participant: Achieving these goals determined by ror e.valnple: participant is NOT required and voluntary_ • Enroll in New School Traekin- of goals by participant is optional. Set Itp Childettre • Get School tfnl forms or Clothii • OTHER: • Not Applicable 1. ❑Yes ❑ In Progress ❑Yes ❑ In Progress OTHER Goals Person/s Responsible Steps needed to reach goal & any Goals Achieved/Outcomes assistance needed (Were goals obtained?) ror example: • Fix Inv Cur Achievilig these goals determined by • .4truv a New Hrbht, parGcipmlt is NOT required and voluntary. IVotApplitrrhle "I"NWkirw of goals by participant is optional. SKY 1S T/tI' 11N11`1:I rrl I . Oyes ❑ In Progress ❑Yes ❑ In Progress 2. Reviewed and updated at each session by client & staff: Participant Signature Date Staff Signature Date (Copies need to always be offered to participant, so they can handwrite any updates or notes they want to take) /Volumeslltl Files/PROGRAMS/RENTAL ASSI.STANCE/HB HOME`TB. A_20I8_20_Contract:Exhibit AtAppendix.%AppendixJ2.doc 7 For Admin Only (This part will only show isp at Exit): Total ff of GoaLv: If of Goals Achieved: % oj'Goals Achieved (Tomd/Achieved): 11o\11- TBRA N I . 26 ( oniiaci.]-Ah' lii Interval House Exhibit B Documentation, Recordkeeping, Reporting and Monitoring Requirements Documentation, Recordkeeping, Reporting and Monitoring Requirements Interval House (Subrecipient) shall comply with the requirements set forth in this document at all times during the term of the HOME Subrecipient Agreement (Agreement) between the City of Huntington Beach (City) and Subrecipient, to which this document is attached. I. Documentation and Recordkeeping A. Records to be Maintained Subrecipient shall maintain all records required by the federal regulations specified in 24 CFR 92.508(a)(3), which are pertinent to the Services to be funded under the Agreement. Records shall be maintained for each prospective participant, each Eligible Household and each Housing Unit inspected and/or occupied by an Eligible Household pursuant to the Agreement. Such records shall include but are not limited to: ■ Records providing a full description of each activity undertaken. ■ Records required to determine the eligibility of activities for use of HOME funds. ■ Records (including property inspection reports) demonstrating that each Housing Unit occupied by an Eligible Household meets the property standards of 24 CFR 92.251(d) and 24 CFR 982.401 upon occupancy and at the time of each annual inspection. ■ Records demonstrating compliance with the property standards and financial reviews and actions pursuant to 24 CFR §92.504(d). ■ Records demonstrating that each Eligible Household is income eligible in accordance with 24 CFR 92.203, including all TBRA applications, eligibility determinations and documentation regarding any appeals of eligibility determinations. ■ Records demonstrating that Subrecipient is in compliance with the City's written tenant selection policies and criteria of 24 CFR 92.209(c), including any targeting provisions of 24 CFR 92.209(h), and calculation of each Subsidy Payment. ■ Records demonstrating that each rental agreement for an Eligible Household receiving Subsidy Payments complies with the tenant and participant protections of 24 CFR 92.253. ■ Records documenting compliance with Subrecipients marketing and outreach obligations under the Agreement, including compliance with the fair housing and equal opportunity components of the HOME program and HUD's Affirmative Fair Housing and Marketing regulations and the City's Affirmative Fair Housing Marketing Plan, when adopted. ■ Records documenting compliance with the lead -based hazards requirements under the Agreement, the HOME Program, and 24 CFR Part 35, subparts A, B, J, K, M and R. ■ Financial records as required by 24 CFR §92.508(a)(5) and 24 CFR §92.222. ■ Records documenting the HOME Matching Contributions made by Subrecipient pursuant to the Agreement and the HOME Program, specifically including 24 CFR 92.218 through 24 CFR 92.222. B. Retention The Subrecipient shall retain all financial records, supporting documents, statistical records, and all other records pertinent to the Agreement for a period of five years after the period of Subsidy Payments terminates. Notwithstanding the above, if there are litigation matters, claims, audits, negotiations or other actions that involve any of the records cited and that have started before the expiration of the five-year period, then all pertinent records must be retained until completion of the actions and resolution of all issues, or the expiration of the five-year period, whichever occurs later. C. Client Data The Subrecipient shall maintain client data demonstrating client eligibility for services provided. Such data shall include, but not be limited to, client name, address, income level or other basis for determining eligibility, and description of service provided. Such information shall be made available to City monitors or their designees for review upon request. D. Disclosure The Subrecipient understands that client information collected under this Agreement is private and the use or disclosure of such information, when not directly connected with the administration of the City's or Subrecipient's responsibilities with respect to Services provided under this Agreement, is prohibited unless written consent is obtained from such person receiving services and, in case of a minor, that of a responsible parent/guardian. E. Close Outs The Subrecipient's obligation to the City shall not end until all close-out requirements are completed. Activities during the close-out period shall include, but are not limited to: making final payments, disposing of program assets (including the return of all unused materials, equipment, unspent cash advances, program income balances, and accounts receivable to the City), and determining the custodianship of records. Notwithstanding the foregoing, the terms of this Agreement shall remain in effect during any period that the Subrecipient has control over HOME funds, including program income. F. Audits and Inspections All Subrecipient records with respect to any matters covered by this Agreement shall be made available to the City, HUD and the Comptroller General of the United States or any of their authorized representatives, at anytime during normal business hours, as often as deemed necessary, to audit, examine, and make excerpts or transcripts of all relevant data. Any deficiencies noted in audit reports must be fully cleared by the Subrecipient within 30 days after receipt by the Subrecipient. Failure of the Subrecipient to comply with the above audit requirements will constitute a violation of the Agreement and may result in the withholding of future payments. The Subrecipient hereby agrees to have an annual agency audit conducted in accordance with current City policy concerning Subrecipient audits and OMB Circular A-122. II. Quarterly Progress Reports Subrecipient shall submit quarterly progress reports to the City in a form approved or directed by the City on or before each April 15, July 15, October 15 and January 15, which shall include all of the following information regarding Subrecipient's activities during the prior quarter: ■ The number of TBRA applications received, processed, approved and disapproved. ■ The number of Housing Units inspected, approved and disapproved and a description of any corrective work performed by Landlords to comply with HQS. • The number of Eligible Households assisted, including specific information regarding the number of and ages of all household members, income categories, types and amounts of assistance provided to each Eligible Household, and remaining terms of assistance expected to be provided to such households. ■ Description of each Eligible Household's participation in required self-sufficiency program and other optional social and supportive Services provided or otherwise made available to each Eligible Household. ■ Budget reconciliation information, including year-to-date expenditures and remaining balance available for Subsidy Payments in accordance with the Budget and the Agreement. ■ Number of additional Eligible Households Subrecipient expects to qualify and assist within the following three-month period. ■ Updated schedule of performance of the Services under the Agreement, including a schedule for qualifying and assisting additional Eligible Households as permitted by the Budget. ■ Information regarding any complaints receipted from Applicants or Eligible Households and any correspondence received from community members or organizations or other nonprofit organizations regarding the Program or specific activities or individuals involved in the Program. ■ Documentation of the HOME Matching Contributions made by Subrecipient pursuant to the Agreement and the HOME Program, specifically including 24 CFR 92.218 through 24 CFR 92.222. III. Performance Monitoring A. Monthly Reports Subrecipient shall provide progress reports on a Monthly basis during the first quarter of the Term of the Agreement in order for the City to review Subrecipient's activities and progress under the Agreement and to ensure that the Program is progressing smoothly. B. City Oversight and Review City will monitor the performance of the Subrecipient against the goals and performance standards set forth in the Agreement. From time to time, City shall be entitled to audit and review Subrecipient's performance of the Services in accordance with the terms of the Agreement and compliance with the HOME Program. Substandard performance as determined by the City will constitute noncompliance with the Agreement. If action to correct such substandard performance is not taken by the Subrecipient within a reasonable period of time after being notified by the City, termination procedures will be initiated in accordance with Section 8.3 of the Agreement. Interval House Exhibit C Gross Income Calculation Form Req. form —HB HOME RENTAL ASSISTANCE PROGRAM Income Information • Income Checklist o Documentation of Income • Declaration of Income Form o Income Regulations • Declaration of Assets and Calculation of Total -Household Income o Asset Regulations • Calculation of Client Contribution; Gap Analysis Req. form =HB HOME Income CHECKLIST Step 1: Staff member interviews client and collects copies of any documentation from checklist below. Attach proof of all income for every household member age 18 or older. All income information/documentation should be collected for the past two months for HB HOME. ***Do not ask an employer to provide documentation, especially if this could jeopardize the client's employment. You should get everything from the client. Income includes but is not limited to: • The full amount of gross income earned before taxes and deductions. • The net income earned from the operation of a business, i.e., total revenue minus business operating expenses. This also includes any withdrawals of cash from the business or profession for your personal use. • Monthly interest and dividend income credited to an applicant's bank account and available for use. • The monthly payment amount received from Social Security, annuities, retirement funds, pensions, disability and other similar types of periodic payments. • Any monthly payments in lieu of earnings, such as unemployment, disability compensation, SSI, SSDI, and worker's compensation. • Monthly income from government agencies excluding amounts designated for shelter, and utilities, WIC, food stamps, and childcare. • Alimony, child support and foster care payments received from organizations or from persons not residing in the dwelling. • All basic pay, special day and allowances of a member of the Armed Forces excluding special pay for exposure to hostile fire. ❑ Copy of Bank Statements for the past two months attached in back pocket of folder. Req. form —HB HOME ❑ Proof of any Employment Income for the past two months is attached in back pocket of folder. (i.e. paycheck stubs, W-2/1099 tax form) ** Employment income should include the total income, before taxes and deductions are taken out. ❑ Proof of any Payments and/or Benefit Income for the past two months is attached in back pocket of folder. Check the types of payments and/or benefits AND attach proof (i.e. notice or stub or deposit statements): ❑ Social Security/SSI ❑ Pension/Retirement ❑ TAN F ❑ Public Assistance ❑ Disability/SSDI ❑ Unemployment Compensation ❑ Workers Compensation ❑ Alimony Payments ❑ Foster Care Payments ❑ Child Support Payments ❑ Armed Forces Income ❑ Other (please specify): ❑ Documentation of any other source of income for the past two months is attached in back pocket of folder. ❑ Proof of school enrollment attached in back pocket of folder, for any household member age 18 or over who is a full-time student. Client Signature: Signature of Staff responsible for assessment: Date: Date: Supervisor Signature: Date: Req. form —HB HOME ❑ Declaration of Income form is filled out by a trained staff member and signed for every household member age 18 or older. ❑ Staff member reviewed Annual Income Inclusions and Exclusions (see attached 24 CFR Part 5 guidelines). Information on all relevant included income has been collected and recorded on form. NO excluded income has been recorded on form. ❑ ALL relevant documentation is attached in back pocket of folder (see boxes in Step 1). ❑ If staff member was unable to obtain third -party verification or documentation, they have described efforts made for third -party verification and attached any documentation of these efforts in back pocket of folder. ❑ Staff member has signed the bottom of the form. Client Signature: Signature of Staff responsible for assessment: Supervisor Signature: Date: Date: Date: M Req. form-HB;HOME Step Declaration of Assets •Calculationof Total Household Income ❑ Declaration of Assets section is filled out by a trained staff member and ALL relevant documentation is attached in back pocket of folder. ❑ Staff member reviewed Net Family Asset Inclusions and Exclusions (see attached 24 CFR Part 5 guidelines). Information on all relevant included assets has been collected and recorded on form. NO excluded assets has been recorded on form. ❑ Total household income is calculated and recorded by a trained staff member on page 2. Client Signature: Signature of Staff responsible for assessment: Supervisor Signature: Date: Date: Date: 5 Req. form —HB HOME **** This information must be collected at intake and 6-month re-evaluation. ❑ Refer to Calculation of Total Household Income (Step 3) to find the household's total annual income. Refer to Demographic Information (Section 1) to find the household size (total number of adults and children). ❑ Does client have an annual household income below 30 percent of median family income for the area, as determined by HUD? ❑ Yes ❑ No Extremely Low (30%) Income Limit for OC (FY 2018): W,'Io�"'s ehold Size Extremely Low Income 30% to 0% 1 Person $ 23,000 - $0 2 Persons $ 26,250 - $0 3 Persons $ 29,550 - $0 4 Persons $ 32,800 - $0 5 Persons $ 34,450 - $0 6 Persons $ 38,050 - $0 7 Persons $ 40,700 - $0 8 or More Persons $ 43,300 - $0 Source: https://www.huduser.gov/portal/datasets/il/il2018/2018summary.odn Client Signature: Signature of Staff responsible for assessment: Supervisor Signature: Date: Date: Date: Il Req. form,::HB HOME ❑ Calculation of Client Contribution form is filled out by a trained staff member. ❑ Gap Analysis form is filled out by a trained staff member and Funds Needed is calculated at the bottom (amount of assistance cannot exceed the amount of funds needed). ** Enter the information into the Gap Analysis spreadsheet on the computer and the spreadsheet will do the math for you. ** Fill out the Schedule of Assistance every 6 months as decisions are made. Client Signature: Date: Signature of Staff responsible for assessment: Date: Supervisor Signature: Date: Step 6: Client Certification I certify, under penalty of perjury, that I have no other income or assets other than what I have stated above certify that all complete. Client's Signature information provided on this form is true and Client's Printed Name Date V/ Req. info / not req. form —HB HOME RULE The Huntington Beach HOME grant requires households to have an income no greater than 30% of the annual median income (AMI) at time of entry. Household income can increase to up to 80% of AMI during participation in program. 24 CFR 92.209 (c) (1) Low-income families. Tenant -based rental assistance may only be provided to very low- and low-income families. The participating jurisdiction must determine that the family is very low- or low-income before the assistance is provided. During the period of assistance, the participating jurisdiction must annually determine that the family continues to be low- income. (h) Maximum subsidy. (1) The amount of the monthly assistance that a participating jurisdiction may pay to, or on behalf of, a family may not exceed the difference between a rent standard for the unit size established by the participating jurisdiction and 30 percent of the family's monthly adjusted income. (2) The participating jurisdiction must establish a minimum tenant contribution to rent. [Huntington Beach has established a minimum tenant contribution of $50 per month.] (3) The participating jurisdiction's rent standard for a unit size must be based on: (i) Local market conditions; or (ii) The Section 8 Housing Choice Voucher Program (24 CFR part 982). 0) Security deposits. (2) The relevant State or local definition of "security deposit" in the jurisdiction where the unit is located is applicable for the purposes of this part, except that the amount of HOME funds that may be provided for a security deposit may not exceed the equivalent of two month's rent for the unit. 24 CFR 92.203 (a) (2) For all other families (i.e., homeowners receiving rehabilitation assistance, homebuyers, and recipients of HOME tenant -based rental assistance), the participating jurisdiction must determine annual income by I Req. info / not req. form —HB HOME examining at least 2 months of source documents evidencing annual income (e.g., wage statement, interest statement, unemployment compensation statement) for the family. (c) Although the participating jurisdiction may use either of the definitions of "annual income" permitted in paragraph (b) of this section to calculate adjusted income, it must apply exclusions from income established at 24 CFR 5.611. The HOME rents for very low-income families established under §92.252(b)(2) are based on adjusted income. In addition, the participating jurisdiction may base the amount of tenant -based rental assistance on the adjusted income of the family. The participating jurisdiction may use only one definition for each HOME -assisted program (e.g., downpayment assistance program) that it administers and for each rental housing project. (d) (1) The participating jurisdiction must calculate the annual income of the family by projecting the prevailing rate of income of the family at the time the participating jurisdiction determines that the family is income eligible. Annual income shall include income from all persons in the household. Income or asset enhancement derived from the HOME -assisted project shall not be considered in calculating annual income. (2) The participating jurisdiction is not required to re-examine the family's income at the time the HOME assistance is provided, unless more than six months has elapsed since the participating jurisdiction determined that the family qualified as income eligible. (3) The participating jurisdiction must follow the requirements in §5.617 when making subsequent income determinations of persons with disabilities who are tenants in HOME -assisted rental housing or who receive tenant -based rental assistance. 9 e %414.44..,4�c ..'k 3 INTERVAL HOUSE Gis9rMrc96"(Wiftl(lhu*% n Req info — LB / Req form — GG/HB/WM/OC HUD-SAMB HOME Rental Assistance Program Step 2 DECLARATION OF INCOME Applicant Name: Income for: A Declaration of Income should be filled out for the head of household and each other household member age 18 or over. Check only one box and complete only that section ❑ I certify, under penalty of perjury, that I currently receive the following income: Income source: Amount: Income source: Income source: ** Employment income should include the total income, before taxes and deductions are taken out. Total Monthly income: Total Expected Annual income: Amount: Amount: Frequency: Frequency: Frequency: Frequency Key: Paid weekly: 52 times/year Paid every other week (biweekly): 26 times/year Paid twice a month (semimonthly): 24 times/year Paid monthly: 12 times/year Please attach any relevant documentation of this household member's income that you collected from the yellow checklist (Step 1) in back pocket of folder. Remember, one of these forms should be filled out for the head of household and each other household member age 18 or over. I certify, under penalty of perjury, that I have no other income or assets other than what I have stated above. Applicant Signature: Date: ❑ I certify, under penalty of perjury, that I do not have any income from any source at this time. Applicant Signature: Date: Staff Verification I understand that third -party verification is the preferred method of certifying income for rental assistance. For third -party verification, you do not have to speak to an employer or other person — you can use any of the income documentation that you collected from the yellow checklist (Step 1). If you were unable to obtain third -party verification or documentation, please explain why. (For example: Contacting the client's employer could jeopardize their job, in certain situations). Staff Signature: Financial supervisor approval signature: Date: Date: INTERVAL HOUSE Gishih Wi(MmfuYdndo=%xMwm Req. info — LB / Req. form — GG/HB/WM/OC HUD -SA/ HB HOME Rental Assistance Program DECLARATION OF ASSETS Applicant Name: Step 3 ASSETS Family Member Asset Description Current Cash Value of Assets Actual Income from Assets 3. Net Cash Value of Assets................................................................................................... 3. 4. Total Actual Income from Assets..................................................................................... 4. 5. If line 3 is greater than $5,000, multiply line by (Passbook Rate) and enter results here; otherwise, leave blank. 5. Please attach documentation of any assets listed in back pocket of folder. CALCULATION OF TOTAL HOUSEHOLD INCOME Add the monthlv and annual incomes from the Declaration of Income forms for all household members. Total Monthly Income Expected Annual Income Household head Household member #2 Household member #3 Household member #4 TOTAL FOR HOUSEHOLD Total Annual Income: Total annual household income from blue box in chart above: + The amount from Line 4 or 5 (whichever is bigger) in the assets table: Total annual income 1 INTERVAL HOUSE On S4m & tents 6 veins d D,xarsfc ViAm Req. form — HB HOME Rental Assistance Program Step 5 CALCULATION OF CLIENT CONTRIBUTION Applicant Name: HB HOME RENT PAYMENT STANDARD EFFICIENCY 1-BEDROOM i 2-BEDROOM 3-BEDROOM 4-BEDROOM FHUNTINGTON BEACH IN/A $1,854 F$2,251 $2,860 $3,788 _ ....................... _ r.. OTHER ORANGE COUNTY— $1 294 $1,520 Ii $1,850 $2,550 $2,800 CENTRAL I ............ .. .............. ........_....... OTHER ORANGE COUNTY— _ __._ _......... ..._... $1 294 .. ............................_.......................... $1,642 .... .... f $1,950 ......... $2,750 $2,800 RESTRICTED . _.. �. .....___..........--- ................... ...... OTHER ORANGE COUNTY _. _ — $1,294 .. ...................._.._ ---- .. __..... _ ._ �$1,400 $1,730 $2,425 $2,800 OTHER LA COUNTY T ....... . ........._ �....... ........... $1,173 $1,412 $1,829 $2,454 ........ I $2,713 *Orange County — Central Cities: Costa Mesa, Fountain Valley, Yorba Linda *Orange County — Restricted Cities: Aliso Viejo, Dana Point, Irvine, Laguna Beach, Laguna Hills, Laguna Niguel, Lake Forest, Mission Viejo, Newport Beach, Rancho Santa Margarita, San Juan Capistrano, San Clemente, Tustin Calculation of Client's Contribution to Rent Family's monthly adjusted income: (from Calculation of Total Household Income) x 0.30 30% of family's monthly adjusted income: _ If utilities not included in rent, Subtract utility allowance for city where they are moving: - (from Utility allowance form in Lease/Landlord section) Client Contribution: _ ** If this calculation results in a contribution less than $50, the Client Contribution shall be set at $SO (this minimum can be waived in exceptional circumstances.) Calculation of Maximum Subsidy from Interval House Rent standard for unit size: (see chart above based on city where housing is) Subtract Client Contribution from above: Maximum subsidy (monthly): _ Interval House Exhibit D Household Budget Worksheet GAP ANALYSIS Applicant Name: MONTHLY INCOME Total Monthly Household Income (from Calculation of Total Household Income) '• This income should already incorporate inclusions and exclusions from 24 CFR Part 5 Total Monthly INCOME MONTHLY EXPENSES Rentallnsurance utilities Water/Sewer/Trash Communication (Phone, Cable, Internet) Maintenance/Supplies/Household Cleaning Other Vehicle Payments Auto Insurance Fuel Bus/Taxi/Train Fare Repairs Registration/License Other Total HOME EXPENSES Total TRANSPORTATION EXPENSES Req. form - GG/HB/WM/OC HUD/LB/SA/HB HOME Step 5 SAVINGS Emergency Fund Transfer to Savings Retirement (401k, IRA) Investments Education Other Total SAVINGS - TAXES "This includes taxes taken out of monthly income Federal Taxes State/Local Taxes Total TAXES - OBLIGATIONS/DEBTS Student Loan Other Loan Credit Cards Alimony/Child Support Medical debts Rental Arrears Other Total OBLIGATIONS/DEBTS - - HEALTH Health Insurance Doctor/Dentist If client has a large amount of either Savings or Medicine/Drugs Obligations/Debts, this should also be taken into account Life Insurance when calculating assistance level. Veterinarian/Pet Care Other ; Total HEALTH EXPENSES Education/Lessons Pet expenses Personal Supplies (toiletries, hygiene, etc.) Clothing Cleaning (laundry, dry cleaning, etc.) Dining/Eating Out Salon/Barber Other Total LMNG EXPENSES - Total Monthly EXPENSES MONTHLY ANALYSIS Total Monthly Expenses $ - Housing Relocation and Stabilization Expenses •• These are one-time expenses of moving into new housing - Total Monthly Income $ - = Funds Needed OR (Funds available) = Maximum initial assistance (assistance cannot exceed funds needed) SCHEDULE OF ASSISTANCE 1st Month / First 6 months (HB HOME) 2nd Month / Second 6 months (HB HOME) 3rd Month / etc. (HB HOME) Total Assistance Interval House Exhibit E Lead -Based Hazard Information Pamphlet "Protect Your Family from Lead in your Home" Req, info/not req form — GG/HB/WM/OC HUD/LB/SA/'HB HOME INTERVAL HOUSE U&UWAt dr wdka Lead Screening Worksheet About this Tool The lead screening worksheet is intended to guide grantees through the lead -based paint inspection process to ensure compliance with the rule. Staff can use this worksheet to document any exemptions that may apply, whether any potential hazards have been identified, and if safe work practices and clearance are required and used. A copy of the completed worksheet along with any additional documentation should be kept in each program participant's case file. Instructions To prevent lead -poisoning in young children, grantees must comply with the Lead -Based Paint Poisoning Prevention Act of 1973 and its applicable regulations found at 24 CFR 35, Parts A, B, M, and R. Under certain circumstances, a visual assessment of the unit is not required. This screening worksheet will help program staff determine whether a unit is subject to a visual assessment, and if so, how to proceed. A copy of the completed worksheet along with any related documentation should be kept in each program participant's file. Note: ALL pre-1978 properties are subject to the disclosure requirements outlined in 24 CFR 35, Part A, regardless of whether they are exempt from the visual assessment requirements. BASIC INFORMATION Name of Participant Address Unit Number City State Zip Program Staff PART 1: DETERMINE WHETHER THE UNIT IS SUBJECT TO A VISUAL ASSESSMENT If the answer to one or both of the following questions is 'no,' a visual assessment is not triggered for this unit and no further action is required at this time. Place this screening worksheet and related documentation in the program participant's file. If the answer to both of these questions is 'yes,' then a visual assessment is triggered for this unit and program staff should continue to Part 2. 1. Was the leased property constructed before 1978? ❑ Yes ❑ No 2. Will a child under the age of six and/or pregnant woman be living in the unit occupied by the household receiving assistance? ❑ Yes ❑ No Req info/not req form — GG/HB/WM/OC HUD/LB/SA/ HB HOME PART 2: DOCUMENT ADDITIONAL EXEMPTIONS If the answer to any of the following questions is 'yes,' the property is exempt from the visual assessment requirement and no further action is needed at this point. Place this screening sheet and supporting documentation for each exemption in the program participant's file. If the answer to all of these questions is 'no,' then continue to Part 3 to determine whether deteriorated paint is present. 1. Is it a zero -bedroom or SRO -sized unit? ❑ Yes ❑ No 2. Has X-ray or laboratory testing of all painted surfaces by certified personnel been conducted in accordance with HUD regulations and the unit is officially certified to not contain lead -based paint? ❑ Yes ❑ No 3. Has this property had all lead -based paint identified and removed in accordance with HUD regulations? ❑ Yes ❑ No 4. Is the client receiving Federal -assistance from another program, where the unit has already undergone (and passed) a visual assessment within the past 12 months (e.g., if the client has a Section 8 voucher and is receiving rental assistance for a security deposit or arrears)? ❑ Yes (Obtain documentation for the case file.) ❑ No 5. Does the property meet any of the other exemptions described in 24 CFR Part 35.115(a). ❑ Yes ❑ No Please describe the exemption and provide appropriate documentation of the exemption. 2 Req''info/not,,req�form = GG/HB/WM/OG HUD/LB/SA/ HB HOME PART 3: DETERMINE THE PRESENCE OF DETERIORATED PAINT To determine whether there are any identified problems with paint surfaces, program staff should conduct a visual assessment prior to providing financial assistance to the unit as outlined in the following training on HUD's website at: http�/[WWw,hud.gov/`offices/lead/training/visuaIassess ment/h00101_ htm. If no problems with paint surfaces are identified during the visual assessment, then no further action is required at this time. Place this screening sheet and certification form (Attachment A) in the program participant's file. If any problems with paint surfaces are identified during the visual assessment, then continue to Part 4 to determine whether safe work practices and clearance are required. 1. Has a visual assessment of the unit been conducted? ❑ Yes ❑ No 2. Were any problems with paint surfaces identified in the unit during the visual assessment? ❑ Yes ❑ No (Complete Attachment A — Lead -Based Paint Visual Assessment Certification Form) PART 4: DOCUMENT THE LEVEL OF IDENTIFIED PROBLEMS All deteriorated paint identified during the visual assessment must be repaired prior to clearing the unit for assistance. However, if the area of paint to be stabilized exceeds the de minimus levels (defined below), the use of lead safe work practices and clearance is required. If deteriorating paint exists but the area of paint to be stabilized does not exceed these levels, then the paint must be repaired prior to clearing the unit for assistance, but safe work practices and clearance are not required. 1. Does the area of paint to be stabilized exceed any of the de minimus levels below? • 20 square feet on exterior surfaces ❑ Yes ❑ No • 2 square feet in any one interior room or space ❑ Yes ❑ No • 10 percent of the total surface area on an interior or exterior component with a small surface area, like window sills, baseboards, and trim ❑ Yes ❑ No If any of the above are 'yes,' then safe work practices and clearance are required prior to clearing the unit for assistance. Req info/not req form — GG/HB/WM/OC HUD/LB/SA/ HB HOME PART 5: CONFIRM ALL IDENTIFIED DETERIORATED PAINT HAS BEEN STABILIZED Program staff should work with property owners/managers to ensure that all deteriorated paint identified during the visual assessment has been stabilized. If the area of paint to be stabilized does not exceed the de minimus level, safe work practices and a clearance exam are not required (though safe work practices are always recommended). In these cases, the program staff should confirm that the identified deteriorated paint has been repaired by conducting a follow-up assessment. If the area of paint to be stabilized exceeds the de minimus level, program staff should ensure that the clearance inspection is conducted by an independent certified lead professional. A certified lead professional may go by various titles, including a certified paint inspector, risk assessor, or sampling/clearance technician. Note, the clearance inspection cannot be conducted by the same firm that is repairing the deteriorated paint. 1. Has a follow-up visual assessment of the unit been conducted? ❑ Yes ❑ No 2. Have all identified problems with the paint surfaces been repaired? ❑ Yes ❑ No 3. Were all identified problems with paint surfaces repaired using safe work practices? ❑ Yes ❑ No ❑ Not Applicable —The area of paint to be stabilized did not exceed the de minimus levels. 4. Was a clearance exam conducted by an independent, certified lead professional? ❑ Yes ❑ No ❑ Not Applicable —The area of paint to be stabilized did not exceed the de minimus levels. 5. Did the unit pass the clearance exam? ❑ Yes ❑ No ❑ Not Applicable — The area of paint to be stabilized did not exceed the de minimus levels. Note:.A copy of the clearance report should be placed in the program participant's file. Req info/not req form — GG/HB/WM/OG.HUD/LB/SA/ HB HOME ATTACHMENT 1: LEAD -BASED PAINT VISUAL ASSESSMENT CERTIFICATION TEMPLATE I, , certify the following: • I have completed HUD's online visual assessment training and am a HUD -certified visual assessor. • I conducted a visual assessment at rft • No problems with paint surfaces were identified in the unit or in the building's common areas. (Signature) (Date) Client Name: Case Number: If you think your home has high levels of lead: Get your young children tested for lead, even if they seem healthy. *Wash children's hands, bottles, pacifiers, and toys often. * Make sure children eat healthy, low -fat foods. ♦ Get your home checked for lead hazards. • Regularly clean floors, window sills, and other surfaces. Wipe soil off shoes before entering house. Talk to your landlord about fixing surfaces with peeling or chipping paint. ♦► Take precautions to avoid exposure to lead dust when remodeling or renovating (call 1-800-424- LEAD for guidelines). ♦ Don't use a belt -sander, propane torch, high temperature heat gun, scraper, or sandpaper on painted surfaces that may contain lead. Don't try to remove lead -based paint yourself. 3 Protect. - - Q � F.� Your ►: -Y From In � S'F f,k Home- -. SEPAProtection United States Environmental Agency United States �- �•�'`� � "Consumer Product t - Safety Commission Fei United States Department of Housing _ r a` and Urban Development Are You Planning To Buy, Rent, Or Renovate a Home Built Before 1978? any houses and apartments built before 1978 have paint that contains high levels of lead (called lead - based paint). Lead from paint, chips, and dust can pose serious health hazards if not taken care of properly. . OWNERS, BUYERS, and RENTERS are encouraged to check for lead (see page 6) before renting, buying or renovating pre- 1978 housing. ederal law requires that individuals receive certain information before renting, buying, or renovating pre-1978 housing: LANDLORDS have to disclose known infor- L mation on lead -based paint and lead -based paint hazards before leases take effect. Leases must include a disclosure about lead -based paint. " - SELLERS have to disclose known informa- tion on lead -based paint and lead -based paint hazards before selling a house. Sales contracts must include a disclosure about lead -based paint. Buyers have up to 10 days to check for lead. RENOVATORS disturbing more than Z square feet of painted surfaces have to give you 00001, this pamphlet before starting work. Lead From Palint, Dust, and Soil Can Be Dangerous If Not Managed Properly FACT- Lead exposure can harm young children and babies even before they are born. FACT Even children who seem healthy can have high levels of lead in their bodies. FACT. People can get lead in their bodies by breathing or swallowing lead dust, or by eating soil or paint chips containing lead. FACT: People have many options for reducing lead hazards. In most cases, lead -based paint that is in good condition is not a hazard. FACT Removing lead -based paint improperly can increase the danger to your family. If you think your home might have lead hazards, read this pamphlet to learn some simple steps to protect your family. Lead Gets in the Body in Many Ways People can get lead in their body if they: Childhood ♦Breathe in lead dust (especially during Ne�� renovations that 'disturb painted poisoning surfaces). remains a put their hands or other objects major covered with lead dust in their mouths. environmen- � Eat paint chips or soil that contains tal health lead. problem in the U.S. Lead is even more dangerous to children under the age of 6: * At this age children's brains and nervous systems are more sensitive to the dam- aging effects of lead. Even children ♦ Children's growing bodies absorb more who appear lead. healthy can * Babies and young children often put have danger- their hands and other objects in their ous levels of mouths. These objects can have lead lead in their dust on them. bodies. Lead is also dangerous to women of childbearing age: J Women with a high lead level in their system prior to pregnancy would expose a fetus to lead through the placenta during fetal development. Lead's Effects It is important to Imow that even exposure to low levels of lead can severely harm children. In children, lead can cause: Nervous system and kidney damage. Learning disabilities, attention deficit Brain or Nerve Damage disorder, and decreased intelligence. Hearing Problerr Speech, language, and behavior problems. Poor muscle coordination. Decreased muscle and bone growth. Slowed Growth Hearing damage. While low -lead exposure is most common, exposure to high levels of lead can have devastating effects on children, including seizures, uncon- sciousness, and, in some cases, death. Although children are especially susceptible to lead exposure, lead can be dangerous for adults too. Digestive. In adults, lead can cause: Problems Increased chance of illness during pregnancy. 4 Harm to a fetus, including brain damage or death. Reproductive Problems (Adults) Fertility problems (in men and women) High blood pressure. Digestive problems. Nerve disorders. Memory and concentration problems. Muscle and joint pain. Least affects the body in many ways. 3 V'Vhere Lead -Based Paint Is Found in �ef➢esrci' Many homes built before 1978 have lead- based paint. The federal government the older YOUr banned lead -based paint from housing in home, the 1978. Some states stopped its use even more lgl e]y it earlier. Lead can be found: %a s lead- ♦ In homes in the city, country, or suburbs. basest paint. 0 In apartments, single-family homes, and both private and public housing. Inside and outside of the house. In soil around a home. (Soil can pick up lead from exterior paint or other sources such as past use of leaded gas in cars.) Cher -king Your Family for Lead To reduce your child's exposure to lead, Get your get your child checked, have your home children and tested (especially if your home has paint home tested in poor condition and was built before if you think 1978), and fix any hazards you may have. your �a*.�%e Children's blood lead levels tend to increase rapidly from 6 to 12 months of age, and has high ie9'- tend to peal( at 18 to 24 months of age. Pi' of lead. Consult your doctor for advice on testing your children. A simple blood test can detect high levels of lead. Blood tests are usually recommended for: 4!� Children at ages 1 and 2. -4� Children or other family members who have been exposed to high levels of lead. ,Q� Children who should be tested under your state or local health screening plan. Your doctor can explain what the test results mean and If more testing will be needed. 4 [dentifyiiia Lead Hazards Lead -based paint is usually not a hazard if it is in good condition, and it is not on an Lead from impact or friction surface, like a window. It paint chips, is defined by the federal government as which you paint with lead levels greater than or equal can see, and to 1,0 mllligram per square centimeter, or more than 0.5% by weight. lead dust, Deteriorating lead -based paint (peeling, which you chipping, chalking, cracking or damaged) cant always is a hazard and needs immediate attention. sue, can both It may also be a hazard when found on sur- he serious faces that children can chew or that get a hazards. lot of wear -and -tear, such as: ♦ Windows and window sills. Doors and door frames. i:� Stairs, railings, banisters, and porches. Lead dust can form when lead -based paint is scraped, sanded, or heated. Dust also forms when painted surfaces bump or rub togeth- er. Lead chips and dust can get on surfaces and objects that people touch. Settled lead dust can re-enter the air when people vacuum, sweep, or walk through it. The following two federal standards have been set for lead hazards in dust: * 40 micrograms per square foot (ug/ft2) and higher for floors, including carpeted floors. * 250 pg/ft2 and higher for interior window sills. Lead in soil can be a hazard when children play in bare soil or when people bring soil into the house on their shoes. The following two federal standards have been set for lead hazards in residential soil: * 400 parts per million (ppm) and higher in play areas of bare soil. 1,200 ppm (average) and higher in bare soil in the remainder of the yard. The only way to find out if paint, dust and soil lead hazards exist is to test for them. The next page describes the most common meth- ods used. Checking Your Home for Lead just knowing that a horse has lead - based paint may not teU you if there is a hazard. 6 You can get your home tested for lead in several different ways: ♦ A paint inspection tells you whether your home has lead -based paint and where it is located. It won't tell you whether or not your home currently has lead hazards. • A risk assessment tells you if your home currently has any lead hazards from lead in. paint, dust, or soil. It also tells you what actions to take to address any hazards. + A combination risk assessment and inspection tells you if your home has any lead hazards and if your home has any lead -based paint, and where the lead -based paint is located. Hire a trained and certified testing profes- sional who will use a range of reliable methods when testing your home. + Visual Inspection of paint condition and location. • A portable x-ray Fluorescence (XRF) machine. • Lab tests of paint, dust, and soil samples. There are state and federal programs in place to ensure that testing is done safely, reliably, and effectively. Contact your state or local agency (see bottom of page 1 1) for more information, or call 1-800-424-LEAD (5323) for a list of contacts in your area. Home test kits for lead are available, but may not always be accurate. Consumers should not rely on these kits before doing renovations or to assure safety. What You Can Do Now To Protect Your Family If you suspect that your house has lead hazards, you can take some immediate steps to reduce your family's risk:. e If you rent, notify your landlord of peeling or chipping paint. Clean up paint chips immediately. Clean floors, window frames, window sills, and other surfaces weekly. Use a mop or sponge with warm water and a general all-purpose cleaner or a cleaner made specifically for lead. REMEMBER: NEVER MIX AMMONIA AND BLEACH PRODUCTS TOGETHER SINCE -THEY CAN FORM A DANGEROUS GAS. Thoroughly rinse sponges and mop heads after cleaning dirty or dusty areas. Wash children's hands often, especial- ly before_ they eat and before nap time and bed time. * Keep play areas clean. Wash bottles, pacifiers, toys, and stuffed animals regularly. * Keep children from chewing window sills or other painted surfaces. Clean or remove shoes before entering your home to avoid tracking in lead from soil. Make sure children eat nutritious, low -fat meals high in Iron and calcium; such as spinach and dairy products. Children with good diets absorb less lead. Reducing Lead Hazards In The Home Removing lead improperly can increase the hazard to your family by spreading even more lead dust arowid the house. Always use a professional vwino is trained to remove lead hazards safely. In addition to day-to-day cleaning and good nutrition: You can temporarily reduce lead hazards by taking actions such as repairing dam- aged painted surfaces and planting grass to cover soil with high lead levels. These actions (called "interim controls") are not permanent solutions and will need ongo- ing attention. To permanently remove lead hazards, you should hire a certified lead "abate- ment" contractor. Abatement (or perma- nent hazard elimination) methods include removing, sealing, or enclosing lead -based paint with special materials. Just painting over the hazard with regular paint is not permanent removal. Always hire a person with special training for correcting lead problems —someone who knows how to do this work safely and has the proper equipment to clean up thoroughly. Certified contractors will employ qualified workers and follow strict safety rules as set by their state or by the federal government. Once the work is completed, dust cleanup activities must be repeated until testing indicates that lead dust levels are below the following: * 40 micrograms per square foot (pglft2) for Floors, including carpeted floors; * 250 ug/ft2 for interior windows sills; and * 400 jtg/ft2 for window troughs. Call your state or local agency (see bottom of page 1 1) for help in locating certified professionals in your area and to see if financial assistance is available. Remodeling or Renovating a Home With Lead -Based Paint Take precautions before your contractor or you begin remodeling or renovating any- thing that disturbs painted surfaces (such as scraping off paint or tearing out walls): �r Have the area tested for lead -Lased paint. Do not use a belt -sander, propane torch, high temperature heat gun, dry scraper, or dry sandpaper to remove lead -based paint. These actions create large amounts of lead dust and fumes. Lead dust can remain In your home long after the work is done. Temporarily move your family (espe- cially children and pregnant women) out of the apartment. or house until the work Is done and the area is prop- erly cleaned. If you can't move your family, at least completely seal off the work area. Follow other safety measures to reduce lead hazards. You can find out about other safety measures by calling 1-800-424-LEAD. Ask for the brochure "Reducing Lead Hazards When Remodeling Your Home." This brochure explains what to do before, during, and after renovations. If you have already completed renova- tions or remodeling that could have released lead -based paint or dust, get your young children tested and follow the steps outlined on page 7 of this ' brochure. If not conducted properly, certain types off renova- tions can release lead from paint and dust into the air. 9 Other Sources of Lead Drinking water. Your home might have plumbing with lead or lead solder. Call your local health department or water supplier to find out about testing your water. You cannot see, smell, or taste lead, and boiling your water will not get rid of lead. If you think your plumbing might have lead in it: Use only cold water for drinking and While paint, dust, cooking. and soil are the Run water for 15 to 30 seconds most common sources of lead, before drinking it, especially if you other lead have not used your water for a few sources also exist. hours. The job. If you work with lead, you could bring it home on your hands or clothes. Shower and change clothes before coming home. Launder your work clothes separately from the rest of your "=-x- family's clothes. 4 Old painted toys and furniture. :- Food and liquids stored In lead crystal or lead -glazed pottery or porcelain. Lead smelters or other industries that release lead into the air. Hobbies that use lead, such as making pottery or stained glass, or refinishing furniture. J� Folk remedies that contain lead, such as "greta" and "azarcon" used to treat an upset stomach. t0 For More Information The National Lead Information Center Call 1-8004244EAD (424-5323) to learn how to protect children from lead poisoning and for other information on lead hazards. To access lead information via the web, visit www.epa.gov/lead and www.hud.gov/offices/leadV. EPA's Safe Drinking Water Hotline Call 1-800-426-4791 for information about lead in drinking water. Consumer Product Safety Commission (CPSC) Hotline To request information on lead in consumer products, or to report an unsafe consumer product or a prod- uct -related injury call 1-800-638- 2772, or visit CPSC's Web site at: www.cpsc.gov. Health and Environmental Agencies Some cities, states, and tribes have their own rules for lead -based paint activities. Check with your local agency to see which laws apply to you. Most agencies can also provide information on finding a lead abatement firm in your area, and on possible sources of financial aid for reducing lead hazards. Receive up-to-date address and phone information for your local con- tacts on the Internet at www.epa.gov/lead or contact the National Lead Information Center at .1-800-424-LEAD, For the hearing impaired, call the Federal Information Relay Service at 1-800-877-8339 to access any of the phone numbers in this brochure. EPA Regional Offices Your Regional EPA Office can provide Further information regard- ing regulations and lead protection programs. EPA Regional Offices Region 1 (Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island, Vermont) Regional Lead Contact U.S. EPA Region Suite 1 100 (CPT) One Congress Street Boston, MA 021 14-2023 1 (888) 372-7341 Region 2 (New Jersey, New York, Puerto Rico, Virgin Islands) Regional Lead Contact U.S. EPA Region 2 2890 Woodbridge Avenue Building 209, Mail Stop 225 Edison, NJ 08837-3679 (732) 321-6671 Region 3 (Delaware, Maryland, Pennsylvania, Virginia, Washington DC, West Virginia) Regional Lead Contact U.S. EPA Region 3 (3WC33) 1650 Arch Street Philadelphia, PA 19103 (215) 814-5000 Region 4 (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee) Regional Lead Contact U.S. EPA Region 4 61 Forsyth Street, SW Atlanta,. GA 30303 (404) 562-8998 Region 5-(Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin) Regional Lead Contact U.S. EPA Region 5 (DT-8J) 77 West Jackson Boulevard Chicago, IL 60604-3666 (312) 886-6003 17 Region 6 (Arkansas, Louisiana, New Mexico, Oklahoma, Texas) Reglonal Lead Contact U.S. EPA Region 6 1445 Ross Avenue, 12th Floor Dallas, TX 75202-2733 (214) 665-7577 Region 7 (Iowa, Kansas, Missourl, Nebraska) Regional Lead Contact U.S.. EPA Region 7 (ARTD-RALI) 901 N. 5th Street Kansas City, KS 66101 (913) 55 1-7020 Region 8 (Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming) Regional Lead Contact US. EPA Region 8 999 18th Street, Suite 500 Denver, CO 80202-2466 (303) 312-6021 Region.9 (Arizona, California, Hawaii, Nevada) Regional Lead Contact U.S. Region 9 75 Hawthorne Street San Francisco, CA 94105 (415) 947-4164 Region 10 (Alaska, Idaho, Oregon, Washington) Regional Lead Contact US. EPA Region 10 Toxics Section WCM-128 1200 Sixth Avenue Seattle, WA 98101-1 128 (206) 553-1985 CPSC Regional Offices Your Regional CPSC Office can provide further information regard- ing regulations and consumer product safety. Eastern Regional Center Western Regional Center Consumer Product Safety Commission Consumer Product Safety Commission 201 Varick Street, Room 903 1301 Clay Street, Suite 610-N New York, NY 10014 Oakland, CA 94612 (21 2) 620-4120 (510) 637-4050 Central Regional_ Center Consumer Product Safety Commission 230 South Dearborn Street, Room 2944 Chicago, IL 60604 (312) 353-8260 HLID Lead Office Please contact HUD's Office of Healthy Homes and Lead Hazard Control for information on lead regulations, outreach efforts, and lead hazard control and research grant programs. U.S. Department of Housing and Urban Development Office of Healthy Homes and Lead Hazard Control 451 Seventh Street, SW, P-3206 Washington. DC 20410 (202) 755-1785 This document is in the public domain. It may be reproduced by an individual or organization without permission. Information provided in this booklet is based upon current scientific and technical understanding of the issues presented and Is reflective of the iurisdictlonal boundaries established by the statutes governing the co-authoririg agencies. Following the advice given will not necessarily pro- vide complete protection in all situations or against all health hazards that can be caused by lead exposure. U.S. EPA Washington DC 20460 EPA747-K-99-001 U.S. CPSC Washington DC 20207 June 2003 U.S. HUD Washington DC 20410 13 Interval House Exhibit F Budget TBRA PROGRAM BUDGET INTERVAL HOUSE HUNTINGTON BEACH, CALIFORNIA Year 1 Year 2 Total 10/1/2018 - 6/30/2019 7/1/2019 - 6/30/2020 Contract HOME Funds Tenant -Based Rental Assistance 123,077 177,779 300,856 and Security Deposits' Administrative Costs HQS Inspections z 6,500 10,000 16,500 Income Eligibility 3 5,200 8,000 13,200 Total HOME Funds 134,777 195,779 330,556 City Inclusionary Funds 4 31,714 42,286 74,000 Total City Contract 166,491 238,065 404,556 Interval House Funding Sources s 91,683 122,245 213,928 Total Budget 258,174 360,310 618,484 1 A total of approximately 22 Eligible Households (9 in Year 1 and 13 in Year 2) can receive assistance for 6 to 12 months per year z Assumes a total of 33 inspections at $500 per inspection (13 in Year 1 and 20 in Year 2). Assumes inspections every six months for each eligible household and some households will need more than one inspection before move -in. Average of 10 hours per Housing Unit. Activities will include inspection advocacy with landlord, agreements with landlord, inspection on -site, travel time, review and approval, and follow-up. 3 Assumes 33 screenings per year at $400 per screening (13 in Year 1 and 20 in Year 2). Assumes income eligibility screenings every six months for each adult and some households will have more than one adult. Average of 8 hours per adult with income. Activities will include income documentation screening, verification and review, calculation of gross, adjusted, exclusions, advocacy with client on income, and follow up. 4 Includes ineligible administrative costs under the HOME Program, such as Intake Assessment, Housing Search, Case Management, Self -Sufficiency, related Support Services, and Overhead. 5 Includes ineligible administrative costs under the HOME Program, such as Intake Assessment, Housing Search, Case Management, Self -Sufficiency, related Support Services, and Overhead that will be funded with other funding sources available to Interval House. Interval House Exhibit G Household Quality Standards (HQS) Inspection Checklist Req form=, HB HOME Inspection Checklist Housing Choice Voucher Program U.S. Department of Housing and Urban Development Office of Public and Indian Housing OMB Approval No. 2577-0169 (Exp. 04/30/2018) Public reporting burden for this collection of information is estimated to average 0.50 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number Assurances of confidentiality are not provided under this collection. This collection of information is authorized under Section 8 of the U.S. Housing Act of 1937 (42 U.S.C. 1437f). The information is used to determine if a unit meets the housing quality standards of the section 8 rental assistance program. Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to collect the information required on this form by Section 8 of the U.S. Housing Act of 1937 (42 U.S C. 1437f). Collection of the name and address of both family and the owner is mandatory. The information is used to determine if a unit meets the housing quality standards of the Section 8 rental assistance program. HUD may disclose this information to Federal, State and local agencies when relevant to civil, criminal, or regulatory investigations and prosecutions. It will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Failure to provide any of the information may result in delay or rejection of family participation. Name of Family Tenant ID Number Date of Request (mm/dd/yyyy) Inspector Neighborhood/Census Tract Date of Inspection (mm/dd/yyyy) Type of Inspection Date of Last Inspection (mm/dd/yyyy) PHA Initial El Special Reinspection A. General Information Inspected Unit Year Constructed (yyyy) 0 Housing Type (check as appropriate Single Family Detached Full Address (including Street, City, County, State, Zip) 0 Duplex or Two Family 0 Row House or Town House 0 Low Rise: 3, 4 Stories, Including Garden Apartment Number of Children in Family Under 6 0 High Rise, 5 or More Stories 0 0 0 Manufactured Home Congregate Cooperative Owner Name of Owner or Agent Authorized to Lease Unit Inspected Phone Number 0 Independent Group 0 Residence Single Room Occupancy Address of Owner or Agent 0 Shared Housing 0 Other B. Summary Decision On Unit (To be completed after form has been filled out Pass Number of Bedrooms for Purposes Number of Sleeping Rooms Fail of the FMR or Payment Standard Inconclusive Inspection Checklist Errs No- 1. Living Room Yes Pass No Fail In- Cori Comment Final Approval Date(mm/dd/yyyy) 1.1 Living Room Present 1.2 Electricity 1.3 Electrical Hazards 1.4 Security 1.5 Window Condition 1.6 Ceiling Condition 1.7 Wall Condition 1.8 Floor Condition Previous editions are obsolete Page 1 of 8 form HUD 52580 (4/2015) ref Handbook 7420.8 Reg:formµ,HB�HOME° Room Codes: 1 = Bedroom or Any Other Room Used for Sleeping (regardless of type of room), 2 = Dining Room or Dining Area, 3 = Second Livinq Room, Family Room, Den, Playroom, TV Room: 4 = Entrance Halls, Corridors, Halls, Staircases; 5 = Additional Bathroom; 6 = Other Item 1. Living Room (Continued) No. Yes Pas No Fail In- Cone. Comment Final Approval Date mm/dd 1.9 Lead -Based Paint Not Applicable Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? 2. Kitchen 2.1 Kitchen Area Present 2.2 Electricity 2.3 Electrical Hazards 2.4 Security 2.5 Window Condition 2.6 Ceiling Condition 2.7 Wall Condition 2.8 Floor Condition 2.9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Not Applicable 2.10 Stove or Range with Oven 2.11 Refrigerator 2.12 Sink 2.13 Space for Storage, Preparation, and Serving of Food 3. Bathroom 3.1 Bathroom Present 3.2 Electricity 3.3 Electrical Hazards 3.4 Security 3.5 Window Condition 3.6 Ceiling Condition 3.7 Wall Condition 3.8 Floor Condition 3.9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Not Applicable 3.10 Flush Toilet in Enclosed Room in Unit 3.11 Fixed Wash Basin or Lavatory in Unit 3.12 Tub or Shower in Unit 3.13 Ventilation Previous editions are obsolete Page 2 of 8 form HUD-5258 (4/2015) ref Handbook 7420.8 itern°.4.Other Rooms Used For Living and Halls Yes m"'In- � � Final Approval Pass rm//c== Comment ___________�___�___________�_____________ 4.1 nuumooue^arm (Circle One) (Circle One) | Room Location Right/Center/Leftpmnm�n��ne� p�o Level ' ---/4.2 Electricity/illumination 4.0Electrical Hazanm 4.4 Security 4.ovmnumwoonumon _-....... -........... ....... _-__-��� 4.6 Ceiling Condition 47W�noonumon ! ! | --- -- -�------T--�- '�''---------------- ------ '-- -'[----'----' 4.8Flom,00numon 4.9 Lead -Based Paint F 'Not Applicable Are all painted surfaces free of detenorated If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? 4.10 Smoke Detectors 4.1 Room Code* and (Circle One) (Circle One) Room Location Right/Center/Left Front/Center/Rear —Floor Level 4.3 Electrical Hazards 4.4 Security 4.5 Window Condition 4.7 Wall Condition 4.8 Floor Condition 4.9 Lead -Based Paint NotApplicable Are all painted surfaces free of deteriorated If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? 4.10 Smoke Detectors 4.1 Room Code* and (Circle One) (Circle One) Room Location Right/Center/Left Front/Center/Rear —Floor Level 4.2 Electricity/Illumination 4.3 Electrical Hazards 4.4 Security 4.5 Window Condition 4,6 Ceiling Condition 4.7 Wall Condition --------------- 4.9 Lead -Based Paint Are all painted surfaces free of deteriorated If not, do deteriorated surfaces exceed two square feet per room and/or is more than txpplicable | — Previous editions are obsolete Page xofa form Huo-5e58o(4/e 15) ref Handbook 7420.8 Req fob B HO HME hem 4. Other Rooms Used For Living and Halls No. yes Pass No Fail In- Conc. Comment Final Approval Date (mm/dd/yyyy) 4.1 Room Code ` and Room Location (Circle One) (Circle One) Right/Center/Left Front/Center/Rear Floor Level 4.2 Electricity/Illumination 4.3 Electrical Hazards _ 4.4 Security 4.5 Window Condition 4.6 Ceiling Condition 4.7 Wall Condition 4.8 Floor Condition 4.9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Not Applicable 4.10 Smoke Detectors 4.1 Room Code' and (Circle One) (Circle One) Room Location Right/Center/Left Front/Center/Rear Floor Level 4.2 Electricityllllumination 4.3 Electrical Hazards 4.4 Security 4.5 Window Condition 4.6 Ceiling Condition 4.7 Wall Condition 4.8 Floor Condition 4.9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Not Applicable 4.10 Smoke Detectors 5. All Secondary Rooms (Rooms not used for living) 5.1 None Go to Part 6 5.2 Security 5.3 Electrical Hazards 5.4 Other Potentially Hazardous Features in these Rooms Previous editions are obsolete Page 4 of 8 form HUD-52580 (412015) ref Handbook 7420.8 Req form - HB HOME Item 6. Building Exterior Yes No In- Final Approval No. Pass Fail 'Conc. Comment Date(mm/dd/yyyy) --6:1--CondTtToh of Foundation ------ 6.2 Condition of Stairs, Rails, and Porches 6.3 Condition of Roof/Gutters 6.4 Condition of Exterior Surfaces 6.5 Condition of Chimney 6.6 Lead Paint: Exterior Surfaces Not Applicable Are all painted surfaces free of deteriorated paint? If not. do deteriorated surfaces exceed 20 square feet of total exterior surface area? 6.7 Manufactured Home: Tie Downs 7. Heating and Plumbing 7.1 Adequacy of Heating Equipment 7.2 Safety of Heating Equipment 7.3 Ventilation/Cooling 7.4 Water Heater 7.5 Approvable Water Supply 7.6 Plumbing 7.7 Sewer Connection 8. General Health and Safety 8.1 Access to Unit 8.2 Fire Exits 8.3 Evidence of Infestation 8.4 Garbage and Debris 8.5 Refuse Disposal 8.6 Interior Stairs and Commom Halls 8.7 Other Interior Hazards 8.8 Elevators 8.9 Interior Air Quality 8.10 Site and Neighborhood Conditions 8.11 Lead -Based Paint: Owner's Certification Not Applicable If the owner is required to correct any lead -based paint hazards at the property including deteriorated paint or other hazards identified by a visual assessor, a certified lead -based paint risk assessor, or certified lead -based paint inspector, the PHA must obtain certification that the work has been done in accordance with all applicable requirements of 24 CFR Part 35. The Lead -Based Paint Owner Certification must be received by the PHA before the execution of the HAP contract or within the time period stated by the PHA in the owner HQS violation notice. Receipt of the completed and signed Lead -Based Paint Owner Certification signifies that all HQS lead -based paint requirements have been met and no re -inspection by the HQS inspector is required. Previous editions are obsolete Page 5 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 Req'formFiB'HOME C. Special Amenities (Optional) This Section is for optional use of the HA. It is designed to collect additional information about other positive features of the unit that may be present. Although the features listed below are not included in the Housing Quality Standards, the tenant and HA may wish to take them into consideration in decisions about renting the unit and the reasonableness of the rent. Checklist any positive features found in relation to the unit. Living Room High quality floors or wall coverings Working fireplace or stove Balcony, patio, deck, porch Special windows or doors Exceptional size relative to needs of family Mj Other: (Specify) 2. Kitchen Dishwasher Separate freezer — Garbage disposal — Eating counter/breakfast nook Pantry or abundant shelving or cabinets Double oven/self cleaning oven, microwave Double sink — High quality cabinets — Abundant counter -top space Modern appliance(s) — Exceptional size relative to needs of family Other: (Specify) 3. Other Rooms Used for Living High quality floors or wall coverings T—1 Working fireplace or stove Balcony, LF-J patio, deck, porch Special windows Lor doors Exceptional size relative to needs of family Other (Specify) 4. Bath Special feature shower head Built-in heat lamp Large mirrors Glass door on shower/tub Separate dressing room Double sink or special lavatory Exceptional size relative to needs of family Other: (Specify) 5. Overall Characteristics Storm windows and doors Other forms of weatherization (e.g., insulation, weather stripping) Screen doors or windows Good upkeep of grounds (i.e., site cleanliness, landscaping, condition of lawn) Garage or parking facilities — Driveway — Large yard — Good maintenance of building exterior Other: (Specify) 6. Disabled Accessibility Unit is accessible to a particular disability. Yes a No Disability Previous editions are obsolete Page 6 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 Req form -.HB HOME 1. Does the owner make repairs when asked? Yes No 2. How many people live there? __ 3. How much money do you pay to the owner/agent for rent? $ _ 4. Do you pay for anything else? (specify) 5. Who owns the range and refrigerator? (insert 0 = Owner or T = Tenant) Range _ Refrigerator Microwave 6. Is there anything else you want to tell us? (specify) Yes ❑ No ❑ Previous editions are obsolete Page 7 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 E. Inspection Summary/Comments (Optional) Provide a summar description of each item which resulted-io-a rating of "Fail" or "Pass with Comments," Tenant ID Number 11 Inspector Date of Inspection (mm/dd/yyyy) Address of Inspected Unit Type of Inspection Initial Special Reinspection Item Number Reason for "Fail' or "Pass with Comments" Rating Continued on additional page Yes 1:1No Previous editions are obsolete Page 8 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 ACORN® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) �� 8/23/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Maureen MoMo McDonald Arthur J. Gallagher & Co. PHONE FAX Insurance Brokers of CA. LIC. # 0726293 818.539.8625 A/C No): 818.539.8725 E-MAIL maureen mcdonald@ajg.com 505 N Brand Blvd, Suite 600 INSURER(S) AFFORDING COVERAGE NAIC# Glendale CA 91203 INSURER A: Berkley National Insurance Company 38911 INSURED INTEHOU-03 INSURER B : New York Marine And General Insurance Company 16608 Interval House P.O. Box 3356 INSURER C INSURER D : Seal Beach, CA 90740 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 1705552221 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR OF INSURANCE ADDTYPE INSD SUER POLICY NUMBER MM POLICY EFF /DD/YYYY POLICY EXP MMIDD/YYYY LIMITS A X COMMERCIAL GENERALLIABILITY Y HHS8525626-11 10/1Y2017 10/12018 EACH OCCURRENCE $1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 100, 000 MED EXP (Any one person) $ 5,000 PERSONAL & AOV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 PRO- X POLICY ❑PRO- ❑ JECT LOC PRODUCTS -COMP/OP AGG $ 3,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS H BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY I $ A UMBRELLA LIAB OCCUR HEN 8565362-11 10/1/2017 10/12018 EACH OCCURRENCE $ 2,000,000 X N AGGREGATE $ 2,000,000 EXCESS LIAB CLAIMS -MADE DIED I X I RETENTION $ Sexual misconduct $ included B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE Y WC201800005078 2/1/2018 2/1/2019 X STATUTE EERH E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 A Property Coverage HHS8525626-11 10/1/2017 10/1/2018 Limit $4,589,200 Deductible $1,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Policy: Crime Coverage APPROVED AS TO FORM Policy Term: 12/01 /2017 - 12/01 /2018 Policy Number: UC11.17-040 n ,•�„�_ 'Y1 �` Carrier: Underwriters at at Lloyd's, London By: Employee theft: Limit : $2,000,000 / Deductible : $25.000 ERISA . Limit : $2,000,000 �� MICHAEL E. GATES Forgery or alteration :'Limit : $2,000,000 / Deductible : $25,000 CITY ATTORNEY Robbery or burglary of other property : Limit : $2,000,000 / Deductible : $25;000 i;TIY OF HUNTINGTON See Attached... BEACH CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Huntington Beach Economic Development ACCORDANCE WITH THE POLICY PROVISIONS. Department Attn: Denise Bazant AUTHORIZEDREP ESENTATIVE AA� � • 2000 Main St., 5th Floor Huntington Beach, CA 92646 t"lQ1 Lt�eti ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: INTEHOU-03 LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY Arthur J. Gallagher & Co. NAMED INSURED Interval House P.O. Box 3356 Seal Beach, CA 90740 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Money and Securities : Limit : $2,000,000 / Deductible: $25,000 Computer fraud : Limit : $2,000,000 / Deductible : $25,000 Funds transfer fraud : Limit : $2,000,000 / Deductible : $25,000 Money orders and counterfeit paper currency : Limit : $2,000,000 / Deductible : $25,000 Cyber Deception : Limit: $150,000 / Deductible : $10,000 Policy: Sexual Abuse Liability Policy Term: 10/01 /2017 to 10/01 /2018 Policy Number: HHS8525626-11 Carrier: Berkley National Insurance Company Each Claim: $1,000,000 ,Aggregate: $3,000,000 Policy: Professional Liability Policy Term: 10/01/2017 to 10/01/2018 Policy Number: HHS8525626-11 Carrier: Berkley National Insurance Company Each Claim: $1,000,000 ,Aggregate: $3,000,000 Policy: Cyber Liability,Retro Date: 7/1/2016,Claims-Made form Policy#:NET 1280674 02 Carrier: Great American Spirit Insurance Company Term: 10/1/2017 to 10/1/2018 Limit: $1,000,000 Aggregate:$1,000,000 , Retention: $5, 000 Re:Certificate holder is named additional insured with respect to the operations of the named insured. Waiver of Subrogation for Workers Compensation policy applies in favor of certificate holder. Such insurance is Primary and Non -Contributory. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: HHS8525626-11 COMMERCIAL GENERAL LIABILITY CG20100413 Berkley National Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered Operations City of Huntington Beach Economic Development Department Attn: Denise Bazant 2000 Main St., 5th Floor Huntington Beach CA 92646 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the. location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed.04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2.00% of the California workers' compensation premium otherwise due on such remuneration. Person or Organization Schedule Job Description Any Person or Organization as Required By Written Contract Any Person or Organization as Required By Written Contract All Operations of the Name Insured This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 2018-02-01 Insured Interval House Insurance Company New York Marine and General Insurance Company / 28746 WC 04 03 06 Policy No. Endorsement No. 1 WC201800005078 Countersigned By (Ed. 04-84) ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. ATTACHMENT #2 City of Huntington Beach 2000 Main Street o Huntington Beach, CA 92648 (714) 536-5227 o www.huntingtonbeachca.gov Office of the City Clerk Robin Estanislau, City Clerk October 8, 2018 Mercy House Attn: Larry Haynes, Executive Director P.O. Box 1905 Santa Ana, CA 92702 Dear Mr. Haynes: Enclosed is a copy of the fully executed "Home Recipient Agreement between the City of Huntington Beach and Mercy House." Sincerely, Robin Estanislau, CIVIC City Clerk RE:ds Enclosure Sister Cities. Anjo, Japan ♦ Waitakere, New Zealand HOME RECIPIENT AGREEMENT BETWEEN THE CITY OF HUNTINGTON BEACH AND MERCY HOUSE (Tenant Based Rental Assistance) This HOME RECIPIENT AGREEMENT (Tenant Based Rental Assistance) ("Agreement") is made and entered into as of DCJD oW IIZOIS("Effective Date") by and between the CITY OF HUNTINGTON BEACH, a municipal corporation and charter city ("City"), and MERCY HOUSE, a California nonprofit public benefit corporation ("Subrecipient"). RECITALS A. City is a California municipal corporation and charter city under the laws of the State of California. B. City has applied for and received funds ("HOME Funds") from the United States Department of Housing and Urban Development ("HUD") pursuant to the HOME Investment Partnerships Act and HOME Investment Partnerships Program, 42 U.S.C. §12701, et seq., and the implementing regulations set forth in 24 CFR § 92.1, et seq. (together, "HOME Program") for the purposes of strengthening public -private partnerships to provide more affordable housing, and particularly to provide decent, safe, sanitary, and affordable housing for very low income and lower income citizens of Huntington Beach in accordance with the HOME Program. As used herein, the HOME Program includes the HUD Final Rule set forth at 78 FR 142, adopted July 24, 2013, which adopts substantial amendments to the HOME Program regulations set forth at 24 CFR Part 92. C. City is currently implementing a coordinated 21-month strategy and program to provide financial assistance to eligible extremely low, very low and lower income families and households to enable such households to secure housing available at an affordable housing cost. D. City has developed and seeks to implement a Tenant Based Rental Assistance Program to assist households in the City, who are homeless or at imminent risk of homelessness, preference given to veterans and seniors, to enable such households to transition into permanent, supportive housing. Seventy-five percent (75%) of new clients referred will be from the Huntington Beach Homeless Task Force. E. City wishes to engage the Subrecipient to assist the City in utilizing HOME Funds to provide tenant based rental assistance and security deposits to households, who are homeless or at imminent risk of homelessness, with preference given to veterans and seniors, to enable such households to transition into permanent, supportive housing. 18-6746/185722/mv 1 F. City wishes to use in -lieu fees generated from the City's Inclusionary Housing Ordinance (Inclusionary Funds) to fund administrative and programmatic costs that are ineligible under the HOME Program regulations. NOW, THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows: ARTICLE 1 SCOPE OF SERVICES 1.1 Scope of Services. During the entire Term (defined below) of this Agreement, Subrecipient shall administer the City's HOME -funded Tenant Based Rental Assistance Program ("TBRA Program"), all in accordance with this Article 1 (collectively, the "Services") and the TBRA Program Operating Guidelines attached hereto as Exhibit A. In connection with the Services, Subrecipient shall comply with all requirements of the HOME Program, this Agreement and all applicable federal, state and local laws and regulations. Subrecipient shall further take all reasonable actions necessary to enable City to comply with City's obligations under the HOME Program relating to the TBRA Program. The Subrecipient shall perform the Services set forth in this Article 1 in furtherance of the TBRA Program. 1.2 Marketing and Outreach; Application Process. (a) Marketing and Outreach. Subrecipient shall undertake affirmative marketing and outreach activities to find prospective Eligible Households interested in the TBRA Program, all in accordance with HUD's Affirmative Fair Housing and Marketing regulations and the City's Affirmative Fair Housing Marketing Plan, when adopted. Subrecipient shall describe its marketing and outreach efforts in quarterly progress reports submitted to the City under this Agreement, as described in Exhibit B. (b) Waiting List. Subrecipient shall maintain a waiting list of prospective Eligible Households. The waiting list shall be prioritized first based on the most urgent need as set forth in the TBRA Program Operating Guidelines, prospective Eligible Households of equally urgent need will be helped on a first come -first served basis, based on the date and time of referral or initial direct contact with the Subrecipient. (c) Intake Process. Upon being contacted by a prospective Eligible Household recruited through Subrecipent's affirmative marketing and outreach efforts, Subrecipient shall initially meet with such prospective Eligible Household to fill out an Initial Qualification Document in 18-6746/185722/mv 2 substantially the form attached as Appendix A to the TBRA Program Operating Guidelines, including an income calculation based on two months of source documentation (bank account statements, pay stubs, etc.) to prequalify such prospective Eligible Household. Subrecipient shall then meet with prequalified Eligible Households to determine and verify their qualifications and eligibility for assistance under the TBRA Program, provide such prequalified Eligible Households with the TBRA Program application and other documentation described below, assist prospective Eligible Households with the completion of the application and gross income calculation worksheet and qualify Eligible Households for the TBRA Program. Subrecipient shall provide every prequalified Eligible Household with all of the following documentation. (i) Seventy-five percent (75%) of new clients will be referred by the Huntington Beach Task Force. The Deputy Director has the authority to waive the requirement. (ii) TBRA Application in the form attached to the TBRA Program Operating Guidelines as Appendix B, or as otherwise approved in writing by the Deputy Director of Business Development on behalf of the City ("Deputy Director"). The TBRA Application shall solicit information regarding each applicant household's income and assets, household size and composition (number of children and adults), names of household members, Housing Unit (defined below) size and location preferences, specific needs and considerations, and a race/ethnicity survey. Examples of acceptable documental to confirm recent residency include: - Copy of previous lease - Copy of previous utility bill - Written confirmation of residency from a previous landlord, or proof of residency in transitional living facility - Copy of school records confirming previous residency Examples of proof of strong ties to the community include: - Current residency of an immediate family member — mother, father, sibling, child, or grandparent - Proof that the individual and/or their dependent(s) attended K- 12 school in Huntington Beach - Written acknowledgement from the Huntington Beach Police Department or Homeless Task Force that individual has been living in Huntington Beach's streets for 18 months. Special Circumstances — the following categories of individuals may meet the definition of Huntington Beach Homeless Resident: 18-6746/185722/mv - Homeless individuals that are "Medically Compromised" - Elderly homeless individuals (60+) - If the Huntington Beach Police Department (HBPD) or Homeless Task Force (HTF) staff believe that an individual's well-being will be severely compromised by living on the street and/or if the individual is a chronic nuisance or offender who's presence in Huntington Beach poses a threat to others or in a consistent drain on public resources, then a team composted of HBPD/HTF may, on a case -by -case basis, determine that such individual qualifies as a HB Homeless Resident. (iii) Declaration of Homelessness Status as appropriate, in the forms attached to the TBRA Program Operating Guidelines as Appendix C. (iv) Rental Assistance Contracts for the Landlord and the Eligible Household, in the forms attached to the TBRA Program Operating Guidelines as Appendix D. (v) Income Calculation Forms in the form attached to this Agreement as Exhibit C. (vi) Household Budget Worksheet (Gap Analysis) in the form attached to this Agreement as Exhibit D. (vii) Lead -Based Hazard Information Pamphlet "Protect Your Family from Lead in Your Home" attached to this Agreement as Exhibit E. (d) Guidance for Eligible Households. Subrecipient shall meet with prospective Eligible Households throughout the application process and shall continue to meet with and counsel each Eligible Household regarding the TBRA Program, the Eligible Household's responsibilities as participants of the TBRA Program, and the goals and objectives of the TBRA Program. 1.3 Determination of Eligibility. Subrecipient shall qualify all Eligible Households in accordance wilh the selection criteria described in this Section. Further, for all Eligible Households Subrecipient shall implement the selection criteria and policies in compliance with the City's Consolidated Plan and the City's housing needs and priorities. (a) Eligible Household. As used in this Agreement, "Eligible Household'' refers to extremely low income households that are (i) currently residents of the City of Huntington Beach, and (ii) currently homeless or at imminent risk of homelessness. 18-6746/ 185 722/mv 4 (1) As used in this Agreement, "homeless" is defined at 24 CFR 91, 582 and 583, as defined by HUD. (ii) For purposes of determining eligibility for the TBRA Program, a prospective Eligible Household's (or for continuing compliance, a participating Eligible Household's) gross annual income shall be determined in accordance with 24 CFR 5.609, with the allowable exclusions from income established at 24 CFR 5.611. For purposes of this Agreement, annual income means the gross amount of income from all sources, including assets, for all adult household members that is anticipated to be received prospectively during the 12-month period following the date of application and before any deductions are taken (and for a participating household, income anticipated for the 12 months following verification described in §1.3(b)(ii) below.) When collecting income verification documentation, Subrecipient may also consider any likely changes in income. (iii) For purposes of this Agreement and the TBRA Program, income limits for extremely -low, very -low and low income households are established annually by HUD for the Orange County income limit area. (b) Income Verification. (i) Initial Verification. To determine if TBRA Program applicants (collectively, "Applicants") are income -eligible, Subrecipient must verify each Applicant's household income using source documentation such as wage statements, interest statements, unemployment compensation statements, bank account statements and other documentation types approved by HUD. Once an initial income verification is completed, the Subrecipient is not required to re-examine the Eligible Household's income unless six months has elapsed before assistance is provided. (ii) Annual Eligibility Verification. Subrecipient shall annually re- certify income and re -qualify each Eligible Household, including examination of source documentation. Household income must be no greater than 80% of AMI to remain eligible for assistance. For households found no longer eligible, assistance must be terminated following a 30-day notification period. (c) Verification of Eligibility. Subrecipient shall collect and examine source documentation submitted by the Applicant to verify the identity of the members of the Eligible Household. Subrecipient shall make a 18-6746/185722/mv 5 determination that the Eligible Household is currently experiencing homelessness or is at imminent risk of homelessness, as defined in the 24 CFR 91, 582 and 583, based on caseworker observations and certification and Applicant certification. (d) Notice of Eligibility Determination. Subrecipent shall provide written or documented verbal notice to each Applicant stating whether such Applicant was detennined to be eligible for assistance under the TBRA Program. Applicants determined to be ineligible for TBRA Program assistance shall have an opportunity to appeal the determination to the Subrecipient's Executive Director. If the issue is not resolved, the case will be referred to the Deputy Director. The definition of "homelessness" under the 24 CFR 91, 582 and 583 is applicable to this Agreement. 1.4 Selection of Housing Units. (a) Housing Unit Selection. Subrecipient shall assist Eligible Households with finding and selecting an appropriate housing unit (each a "Housing Unit") that meets federal housing quality standards ("HQS") or such other standards as may be made applicable to the TBRA Program by HOME Program statutes and/or regulations, specifically including Uniform Physical Condition Standards (UPCS), and that satisfies the requirements of the TBRA Program, HOME Program and this Agreement. Eligible Households shall also be entitled to find a Housing Unit for themselves, subject to compliance with the requirements of the TBRA Program, HOME Program and this Agreement; however, the parties anticipate that in most cases, Subrecipient shall be responsible for locating and qualifying an appropriate Housing Unit for occupancy by each Eligible Household. Subrecipient may refer Eligible Households to appropriate Housing Units but may not require an Eligible Household to select a particular Housing Unit. Subsidy Payments shall only be provided in connection with the rental of a qualified Housing Unit located in the City, unless Subrecipient documents reason for selecting housing outside the city. Subsidy Payments under this Agreement are portable within the City. Subrecipient's obligations under this Section 1.4 apply to each Housing Unit to be occupied by an Eligible Household receiving Subsidy Payments hereunder. (b) Housing Unit Size; Occupancy Standards. Housing unit selection shall comply with the following "Occupancy Standards" for the applicable Eligible Household: No more than two persons per bedroom plus one may occupy the Housing Unit. Thus, no more than three persons may occupy a one -bedroom Housing Unit, no more than five persons may occupy a two bedroom Housing Unit; no more than seven persons may occupy a three bedroom Housing Unit; no more than nine persons may occupy a four bedroom Housing Unit. 18-6746/185722/mv 6 (c) Property Inspection. Prior to occupancy of any Housing Unit by an Eligible Household, and again during the annual (or more often) verification process, Subrecipient shall cause a certified HQS inspector to inspect each Housing Unit occupied or to be occupied by an Eligible Household to ensure the Housing Unit complies with HQS as set forth in the HOME Program, including without limitation 24 CFR 92.251, as well as all applicable state and local codes and ordinances, including zoning ordinances. Subrecipient shall provide the City with documentation of each HQS inspector's certification. Each HQS inspection shall include all of the following: (i) Verification of the age of the Housing Unit (on Rent Reasonableness Form (Appendix G); (ii) Complete HQS Inspection Checklist in the form attached as Exhibit G, including a rating for the Housing Unit of Pass, Pass with Comment, or Fail; (iii) Lead -based hazard assessment, dissemination of lead -based hazard information pamphlet and disclosure form and lead -based hazard reduction activities, if required by the HOME Program or applicable federal, state and/or local laws; (iv) Adequate opportunity for the Landlord (defined below) to correct any deficiencies indicated in the HQS Inspection Form to bring the Housing Unit into compliance with HQS requirements; (v) Verification that occupancy by the Eligible Household will comply with the Occupancy Standards set forth in Section 1.4(b); and (vi) Certification of rent reasonableness regarding the rent being charged for the Housing Unit based on comparable non -assisted Housing Units in the same area. Subrecipient shall perform the rent reasonableness review as approved by the City. City may elect to perform the rent reasonableness reviews on behalf of Subrecipient by providing written notice to Subrecipient. The rent charged under the written lease agreement for the Housing Unit shall conform to the Rent Reasonableness Standard pursuant to Appendix F of the TBRA Program Operating Guidelines, which is based on local market conditions. The contract rent for Housing Units that are restricted to an affordable rent by agreement with the City or by regulation or ordinance, or otherwise, shall be likewise restricted to such affordable rent in accordance with the contractual, statutory or regulatory restrictions governing the permitted rents for such Housing Units and the Rental Assistance 18-6746/185722/mv 7 Subsidy Payment shall be limited and calculated accordingly, as described in Section 1.5(a), below. (d) Coordination with Landlords. (i) Landlord Guidance. Subrecipient shall provide guidance to the property owners, property owners' representatives, or property management companies hired by property owners (each a "Landlord" and collectively referred to as "Landlords'') participating in the TBRA Program regarding the TBRA Program requirements and procedures that impact Landlords. (ii) Landlord Agreement. Subrecipient shall enter into a Landlord Agreement with each participating property owner/Landlord in substantially the form attached to the TBRA Program Operating Guidelines as Appendix E. The Landlord Agreement will establish the Subsidy Payments to be made by Subrecipient on behalf of the Eligible Household as well as the Eligible Household's initial share of the contract rent. The Landlord Agreement shall further establish the terms and conditions under which the Subsidy Payments shall be paid to the Landlord for the applicable Housing Unit, including applicable HOME Program requirements. The Landlord Agreement shall have an initial term of 6-12 months, subject to extensions approved by Subrecipient and City (as applicable) pursuant to the TBRA Program Operating Guidelines. (Ili) Tenant Protection Agreement. Subrecipient shall require each Landlord to enter into a lease agreement with a term of 12 months with any Eligible Household occupying a Housing Unit owned and/or managed by such Landlord, which lease agreement shall include a Tenant Protection Agreement in substantially the form attached to the TBRA Program Operating Guidelines as Appendix F, or an updated form of Tenant Protection Agreement as may be prepared and provided by the City to the Subrecipient, and then by Subrecipient to Landlord. The Tenant Protection Agreement shall be executed in connection with the lease agreement between the Landlord and Eligible Household. The Tenant Protection Agreement will prohibit the inclusion of prohibited lease terms listed at 24 CFR 92.253; Confirm the landlord's obligation to maintain the Housing Unit in accordance with HQS, as established at 24 CFR 982.401; and prohibit discrimination by the landlord against the Eligible Household. Mercy House will review the lease agreement to confirm its compliance with state law and all HOME Program requirements. If the Landlord's form of rental agreement is not acceptable, Subrecipient shall require the Landlord and 18-6746/185722/mv 8 Eligible Household to enter into a lease agreement that complies with state law, HOME requirements, and City requirements. 1.5 Subsidy Payments. Subrecipient shall make rent payments and security deposit payments, as applicable (collectively, the "Subsidy Payments"), to Landlords, on behalf of Eligible Households. Subsidy payments must be provided in accordance to the Subrecipient's TBRA Program Operating Guidelines. Eligible Households are not expected to repay Subsidy Payments received pursuant to the TBRA Program. Except as may be permitted by the HOME Program, Subrecipient's sole remedy in the event of noncompliance or breach by an Eligible Household shall be non -renewal of assistance under the TBRA Program. (a) Rental Assistance Calculation. Subrecipient shall calculate the "Rental Assistance" payments to be paid on behalf of each Eligible Household under this Agreement. The maximum amount of monthly assistance that Mercy House may pay on behalf of a family is the difference between the rent standard for the unit size and 30% of the household's monthly adjusted income. (b) Payment Standards. Subrecipient must use the payment standards as set forth in the Rent Reasonableness Standards attached to the TBRA Program Operating Guidelines as Appendix G. The payment standard represents the cost of rent and utilities for moderately priced units in Huntington Beach. Payment standards are established by bedroom size. (c) Utility Allowance. When utilities are included in the cost of renting a unit, that is, the owner assumes responsibility for payment for all utility services, the Eligible Households entire share of the housing costs will go directly to the owner. When the cost of utilities is not part of the rent, that is, the Eligible Household is directly responsible for payment of utility services, the Eligible Household's initial share of monthly rent will be determined by subtracting a utility allowance from 30% of the Eligible Household's gross monthly income. The Subrecipient must use the County of Orange's Housing Authority's Utility Allowance Schedule attached to the TBRA Program Operating Guidelines as Appendix H. (d) Term. The Subrecipient will provide rental assistance for an initial term of 6-12 months, which can be extended in 6-12 month intervals for a cumulative term of up to 24 months. Extensions will be granted at the discretion of the Subrecipient and shall be based on continued program compliance and ongoing need. The Subrecipient will evaluate ongoing need. (e) Security Deposit Assistance. Subrecipient may provide security deposit assistance to each Eligible Household. It is anticipated that Subrecipient shall provide Security Deposit Assistance to each Eligible Household in an 18-6746/185722/mv 9 amount no greater than 2 months' rent. The lease agreement must provide that the security deposit is refundable in accordance with state law. Security deposit refunds shall be provided by the Landlord directly to the Eligible Household. Any disputes involving the return, or lack thereof, of a security deposit shall be settled by Eligible Household and landlord, as provided for in the lease. (d) Utility Deposit Assistance. Subrecipient may provide utility deposit assistance to each Eligible Household. It is anticipated that Subrecipient shall provide Security Deposit Assistance to each Eligible Household in an amount no greater than 2 months' rent. The lease agreement must provide that the security deposit is refundable in accordance with state law. Security deposit refunds shall be provided by the Landlord directly to the Eligible Household. Any disputes involving the return, or lack thereof, of a security deposit shall be settled by Eligible Household and landlord, as provided for in the lease. 1.6 Administrative Cost Reimbursements The City will reimburse the Subrecipient for allowable costs incurred in administering the TBRA Program, which are associated with the determination of income eligibility, pursuant to 24 CFR 92.203, and property inspections under HQS, codified per 24 CFR 982.401. Administrative costs incurred in administering the TBRA Program that are ineligible under the HOME Program will be reimbursed from a non -HOME Program funding source, or Inclusionary Funds. The administrative costs to be reimbursed from the Inclusionary Funds include Intake Assessments, Housing Search, Case Management, Self -Sufficiency and related services and overhead. 1.7 Termination of Assistance and Returning Eligible Households. (a) Termination of Rental Assistance. Subrecipient may terminate assistance under the TBRA Program for any of the following reasons: (i) Eligible Household is evicted from the Housing Unit based on behavioral issues or unlawful activity; (ii) Eligible Household has violated TBRA participant agreement. (iii) Eligible Household will be assisted by another rental assistance program such as the Section 8 Tenant -Based or Project -Based Programs. Participation in any other rental assistance program is considered a duplicative subsidy therefore all HOME funded rental assistance must be terminated. 18-6746/185722/mv 10 1.8 Returning Eligible Households. As needed, Eligible Households may be allowed to return to the program for rental assistance. A determination to allow re-entry shall be based on the following criteria: (1) Eligible Households must have left the program in good standing. To be in good standing, Eligible Households must have been engaged in their case management plan, voluntarily left the program (not in lieu of termination) or have been released because their household income exceeded eligibility limits. In general, Eligible Households will not be allowed to re-enter the program if they were terminated for non-compliance. (ii) At the discretion of the Subrecipient, a request for re -admission from a prospective Eligible Household previously terminated due to non-compliance may be considered when compelling reasons exist. In such cases, re -admission will require concurrence from the City. (iii) Eligible Households may return so long as the previous rental assistance did not exceed 24 months. Cumulatively, Eligible Households may not receive rental advice for more than a cumulative period of 24 months unless such assistance is permitted by the HOME Program and approved by the City. 1.9 Additional Requirements. (a) Self -Sufficiency Program. Subrecipient shall request each Eligible Household receiving Subsidy Payments from the Subrecipient to participate in Housing Stabilization Case Management administered by Subrecipient and in accordance with the Case Management and Self Sufficiency Program Policies and Procedures attached to the TBRA Program Operating Guidelines as Appendix L Failure of an Eligible Household that is already receiving Subsidy Payments to participate in the Self -Sufficiency Program shall not be grounds for termination of the Subsidy Payments, but may be grounds for non -renewal of Subsidy Payments upon expiration of the subsidy term. (b) No Fees. Subrecipient may not charge fees to any Eligible Household for the Services, Subsidy Payments, Case Management or other services or assistance to be provided to Eligible Households under this Agreement. 1.10 Schedule of Performance. Subrecipient shall use its best efforts to perform the Services in accordance with the following schedule: (a) Affirmative marketing and outreach activities required by this Agreement shall commence immediately upon execution of this Agreement. 18-6746/185722/mv I 1 (b) Subrecipient shall qualify Eligible Households, conduct HQS inspections, approve Housing Units, and move Eligible Households into approved Housing Units in accordance with the following milestone schedule: (i) Subrecipient shall process intake paperwork for and verify eligibility for TBRA Program assistance ("Enroll") for not fewer than three (3) Eligible Households within three (3) months following execution of this Agreement. As program income becomes available and/or additional HOME Funds are contributed to the TBRA Program, Subrecipient shall use diligent efforts to Enroll additional Eligible Households within not more than three (3) months following written notice from the City that such additional funds are expected to become available. (ii) Subrecipient shall assist each Enrolled Eligible Household in finding an appropriate Housing Unit and shall conduct an HQS inspection of such Housing Unit, all within two (2) months following Enrollment of such Eligible Household. (iii) Subrecipient shall commence providing Subsidiary Payments on behalf of each Eligible Household and shall assist each Eligible Household to move into an HQS-inspected and approved Housing Unit, all within three (3) months following Enrollment/Intake of such Eligible Household. (c) Subrecipient shall request each Eligible Household to commence participation in the self-sufficiency program immediately upon Enrollment of such Eligible Household, whether or not such Eligible Household has yet moved into a Housing Unit and received the benefit of Subsidy Payments hereunder. 1.11 City Oversight and Approval Rights. City shall have the right, by written notice to Subrecipient at any time during the Term of this Agreement, to require City review of any of the Services to be performed or pre -approval of service tools and procedures by Subrecipient hereunder, including for example income determinations, qualification of applicants as "Eligible Households," qualification of Housing Units, determination of reasonable rents, etc., to ensure compliance with the TBRA Program, the HOME Program, or other applicable requirements. ARTICLE 2 TERM 2.1 Term. Services of the Subrecipient under this Agreement shall start on 10/1/2018 and end on the earlier to occur of (i) 6/30/2020 or (ii) the date the full amount of HOME Funds available under Section 3.2(a) below has been disbursed to 18-6746/185722/mv 12 Subrecipient and expended by Subrecipient to provide Subsidy Payments pursuant to this Agreement ("Term"), unless this Agreement is earlier terminated pursuant to Section 8.3. The Term of this Agreement and the provisions herein shall be further extended to cover any additional time period during which the Subrecipient remains in control of HOME Funds or other HOME assets, including program income. ARTICLE 3 BUDGET AND PAYMENTS 3.1 Budget. Subrecipient has submitted a budget to City for approval ("Budget"), which sets forth the estimated timing and use of the HOME Funds and Inclusionary Funds contributed by the City pursuant to this Agreement. The Budget is attached hereto as Exhibit F. Any amendments to an approved Budget for the Services must be approved by the City's Director or his authorized designee. In the event this Agreement is extended past the initial Term or any additional moneys will be contributed to the TBRA Program by City pursuant to this Agreement, Subrecipient shall prepare and submit to the Deputy Director for approval an updated Budget for such additional moneys. Subrecipient shall prepare a Budget, for approval by Deputy Director, for each year during which this Agreement remains in effect. The City may require a more detailed line item breakdown of the Budget than the one contained herein, and the Subrecipient shall provide such supplementary information about the Budget in a timely fashion in the form and content prescribed by the City. 3.2 Reimbursement of Subsidy Payments. City shall reimburse Subrecipient for Subsidy Payment actually disbursed to or on behalf of Eligible Households pursuant to this Agreement and in accordance with line items on the approved Budget or as otherwise approved by the City's Deputy Director. City shall have no obligation to reimburse Subrecipient for ineligible administrative costs or expenses incurred by Subrecipient to manage or implement the TBRA Program or this Agreement, for the cost of social or supportive services provided to Eligible Households hereunder, or for any other costs or expenses incurred by Subrecipient in connection with its activities under this Agreement. City's payment obligations hereunder shall be limited to the actual amount of Subsidy Payments disbursed by Subrecipient and eligible administrative costs in accordance with the terms of this Agreement and the approved Budget. Payments may be contingent upon certification of the Subrecipient's financial management system in accordance with the standards specified in 24 CFR 84.21. (a) Amount of Payments. It is expressly agreed and understood that the total amount of HOME Program funds to be paid by the City under this Agreement shall not exceed Four Hundred and One Thousand Four Hundred ($401,400). The amount of Inclusionary Funds to be paid by the City under this Agreement shall not exceed Ninety Two Thousand ($92,000). The dollar amounts stated in the immediately preceeding l 8-6746/l 85722/mv 13 sentences may be increased by written amendment of this Agreement, signed by an authorized representative of Subrecipient and the Director. (b) Requests for Payments. To receive each payment under this Agreement, Subrecipient shall submit to the City a written reimbursement request or invoice in a form approved by City, along with such supporting documentation as may be requested by the City to verify Subrecipient's performance of the Services for which the payment is requested. Reimbursement requests shall be submitted no more frequently than one time per month. Payments will be adjusted by the City in accordance with fund advances, if any, balances available in Subrecipient accounts. In addition, the City reserves the right to liquidate funds available under this Agreement for costs incurred by the City on behalf of the Subrecipient. 3.3 Payments Subject to Availability of HOME Funds. City's obligation to provide payments to Subrecipient hereunder is subject to City's receipt of HOME Funds from HUD pursuant to the HOME Program. 3.4 Accounting. Subrecipient shall, upon request, provide City with an accounting report, in form and content reasonably satisfactory to City, of any funds disbursed by City pursuant to Section 3.2. ARTICLE 4 INSURANCE AND INDEMNIFICATION 4.1 Insurance. Without limiting City's right to indemnification, Subrecipient shall secure prior to commencing the performance of any Services under this Agreement, and maintain during the Term of this Agreement, insurance coverage as set forth in this Section. (a) Workers' Compensation. For the duration of this Agreement, the Subrecipient and all subcontractors, consultants, and agents shall maintain Workers' Compensation Insurance in the amount and type required by California Law, if applicable. (b) Insurance. The Subrecipient, in order to protect the City, its agents, officers and employees against all claims and liability for death, injury, loss and damage as a result of the Subrecipient's or any and all Subrecipient actions in connection with this Agreement and the services required hereunder, shall secure and maintain for the duration of this Agreement insurance as described below. Commercial general liability insurance with a combined single limit of not less than one million dollars ($1,000,000) per occurrence. Claims made and modified occurrence policies are not acceptable. Such insurance shall include completed operations 18-6746/ 185 722/mv 14 liability, personal injury liability, and broad form property damage coverage. Such insurance, to be obtained from a reliable insurance carrier authorized to do such insurance business in the State of California, shall (a) expressly name the City, its agents, officers, and employees as additional insured; and (b) by primary with respect to any insurance or self-insurance programs maintained by the City or any other person or company; and (c) contain cross liability provisions and waiver of subrogation rights acceptable to the City. 2. Commercial automobile liability insurance with a combined single limit of not less than one million ($1,000,000) per occurrence. Such insurance shall include completed operations liability, personal injury liability, and broad form property damage coverage. Such insurance, to be obtained from a reliable insurance carrier authorized to do such insurance business in the State of California, shall (a) expressly name the City, its agents, officers and employees as additional insured; and (b) be primary with respect to any insurance or self-insurance programs maintained by the City or any other person or company; and (c) contain cross - liability provisions and waiver of subrogation rights acceptable to the City. 3. If the Subrecipient employs any person for the purpose of providing any and all advise, counseling and/or treating clients, the Subrecipient shall secure and maintain professional liability insurance (E&O coverage) with a limit of not less than one million dollars ($1,000,000). 4. Employment Practices Liability insurance in amounts commercially available and reasonably available to Subrecipient. 5. Such other insurance coverage or amounts reasonably requested in writing by the City. The Subrecipient shall furnish evidence of the insurance required herein, satisfactory to City Manager and the City's Risk Manager, consisting of certified copies of insurance policies and endorsements or properly executed certifications of insurance to the City in form and substance acceptable to the City and evidencing the required insurance prior to receiving funds under this agreement or commencement of services under this Agreement, whichever occurs first. Such certificates or policies shall: (i) Require thirty (30) days written notice to City, by certified mail, of any cancellation or reduction in available limits, or changes in the terms of coverage; 18-6746/185722/mv 15 (ii) Clearly evidence all coverage required above, including, if certificates are provided, attachment to any certificates of insurance a separate additional insured endorsement page (Form No. CG 20 10 11 85) naming the City and its agents, officers, and employees, as additional insured; and (iii) Indicate whether coverage is on a claims made or occurrence basis. Such insurance shall be maintained prior to commencement until completion of work under this Agreement, if an occurrence policy form is used. If a claims made policy is used, overage shall be maintained during the term of this Agreement and for a period extending five (5) years beyond the Agreement termination date. The Subrecipient shall replace such certificates for policies expiring prior to completion of work under this Agreement and shall continue to furnish certificates five (5) years beyond that time, when and if the Subrecipient has claims made form(s). All insurance shall be issued by a company or companies listed in the current "Best Key Rating Guide: publication with a minimum of a "B+, V" rating; or in special circumstances, as pre -approved by the City Clerk and City Attorney. Insurance coverage in the minimum amounts set forth herein shall not be construed to relieve the Operating Agency from Liability in excess of such coverage, or shall it preclude the City from taking such other actions as are available to it under any provision of this Agreement or otherwise in law. If the Subrecipient, for any reason, fails to maintain insurance coverage, which is required pursuant to this Agreement, the same shall be deemed a material breach of this Agreement. The City, at its sole option, may terminate this Agreement and obtain damages from the Subrecipient resulting from said breach. Alternatively, the City may purchase such required insurance coverage without further notice to the Subrecipient. The City may deduct from sums due to the Subrecipient any premiums and associated costs advanced by the City for such instances. If the balance of monies obligated to the Subrecipient pursuant to this Agreement is insufficient to reimburse the City for the premiums and any associated costs, the Subrecipient agrees to reimburse the City for the premiums and pay for all costs associated with the purchase of said insurance. 4.2 Indemnification. (a) As respects acts, errors or omissions in the performance of Services under this Agreement, the Subrecipient agrees to defend, indemnify and hold 18-6746/185722/mv 16 harmless City, its officers, agents, employees, representatives and volunteers from and against any and all claims, demands, defense costs, liability or consequential damages of any kind or nature arising directly out of the Subrecipient's negligent acts, errors or omissions in the performance of Services under the terms of this Agreement. (b) As respects all acts or omissions which do not arise directly out of the performance of Services, including but not limited to those acts or omissions normally covered by general and automobile liability insurance, Subrecipient agrees to indemnify, defend (at City's option), and hold harmless City, its officers, agents, employees, representatives, and volunteers from and against any and all claims, demands, defense costs, liability, or consequential damages of any kind or nature arising out of or in connection with Subrecipient's performance or failure to perform, under this Agreement; excepting those which arise out of the sole negligence of City. ARTICLE 5 ADMINISTRATIVE REQUIREMENTS 5.1 Financial Management. (a) Accounting Standards. Subrecipient agrees to comply with 24 CFR 84.21 through 84.28 and agrees to adhere to the accounting principles and procedures required therein, utilize adequate internal controls, and maintain necessary source documentation for all costs incurred. (b) Cost Principles. Subrecipient shall administer its program in conformance with OMB Circulars A-122, "Cost Principles for Non -Profit Organization." These principles shall be applied for all costs incurred whether charged on a direct or indirect basis. 5.2 Documentation, Recordkeeping, Reporting and Monitoring. Subrecipient shall maintain documents and records, prepare and submit reports, and permit City to monitor Subrecipient's activities all in accordance with the requirements set forth in Exhibit B and applicable laws and regulations. All requirements set forth in such Exhibit B are incorporated herein as if set forth in full in this Agreement. 5.3 Program Income. Not applicable. 5.4 Use and Reversion of Assets. The use and disposition of property and equipment under this Agreement shall be in compliance with the requirements of 24 CFR Part 84 and 24 CFT 92.504, as applicable. The Subrecipient shall transfer to the City any HOME Funds on hand and any accounts receivable 18-6746/185722/mv 17 attributable to the use of HOME Funds under this Agreement at the time of the earliest to occur of expiration, cancellation, or termination. 5.5 Ownership of Documents. All documents and materials, both tangible and intangible, furnished by or through the City to Subrecipient pursuant to this Agreement are and shall remain the property of City and shall be returned to City upon the earliest to occur of expiration, cancellation, or termination of this Agreement. All documents and materials prepared by Subrecipient under or related to this Agreement shall become the property of City at the time of payment to Subrecipient of all fees, if any, for their preparation, and shall be delivered to City by Subrecipient at the request of City, and in any event upon the earliest to occur of expiration, cancellation, or termination of this Agreement. ARTICLE 6 PERSONNEL & PARTICIPANT CONDITIONS 6.1 Civil Rights. (a) Compliance. The Subrecipient agrees to comply with the Huntington Beach Municipal Code, Government Code Section 4450, et seq., the Unruh Civil Rights Act, Civil Code Section 51, et seq., Title VI of the Civil Rights Act of 1964, as amended, Title VIII of the Civil Rights Act of 1968 as amended, Section 104(b) and Section 109 of Title 1 of the Housing and Community Development Act of 1974, as amended, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990, the Age Discrimination Act of 1975, Executive Order 11063, and Executive Order 11246 as amended by Executive Orders 11375, 11478, 12107 and 12086. (b) Nondiscrimination. The Subrecipient agrees to comply with (1) the requirements of 24 CFR Part 5, subpart A, which relate to nondiscrimination and equal opportunity; (2) the nondiscrimination requirements of Section 282 of the HOME Investment Partnerships Act, 42 U.S.C. Section 12701, et seq. (c) Section 504. The Subrecipient agrees to comply with all federal regulations issued pursuant to compliance with Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), which prohibits discrimination against the individuals with disabilities or handicaps in any federally assisted program. 6.2 Affirmative Action. (a) Executive Order 11246. The Subrecipient agrees that it shall be committed to carry out pursuant to the City's specifications an Affirmative 18-6746/ 185722/mv 18 Action Program in keeping with the principles as provided in President's Executive Order 11246 of September 24, 1966. (b) Women- and Minority -Owned Businesses (W/MBE). The Subrecipient will use its best efforts to afford small businesses, minority business enterprises, and women's business enterprises the maximum practicable opportunity to participate in the performance of this Agreement. As used in this Agreement, the term "small business" means a business that meets the criteria set forth in Section 3(a) of the Small Business Act, as amended (15 U.S.C. 632), and "minority and women's business enterprise" means a business at least fifty-one percent (51%) owned and controlled by minority group members or women. For the purpose of this definition, "minority group members" are Afro-Americans, Spanish-speaking, Spanish surnamed or Spanish -heritage Americans, Asian -Americans, and American Indians. The Subrecipient may rely on written representations by businesses regarding their status as minority and female business enterprises in lieu of an independent investigation. (c) Equal Employment Opportunity and Affirmative Action (EEO/AA) Statement. The Subrecipient will, in all solicitations or advertisements for employees placed by or on behalf of the Subrecipient, state that it is an Equal Opportunity or Affirmative Action employer. (d) Subcontract Provisions. The Subrecipient will include the provisions of Sections 6.1, Civil Rights, and 6.2, Affirmative Action, in every subcontract or purchase order, specifically or by reference, so that such provisions will be binding upon each of its own sub-subrecipients or subcontractors. 6.3 Employment Restrictions. (a) Prohibited Activity. The Subrecipient is prohibited from using HOME Funds provided herein or personnel employed in the administration of the program for: political activities; inherently religious activities; lobbying; political patronage; and nepotism activities. (b) Labor Standard. The Subrecipient agrees to comply with the requirements of the Secretary of Labor in accordance with the Davis - Bacon Act as amended, the provisions of Contract Work Hours and Safety Standards Act (40 U.S.C. 327 et seq.) and all other applicable federal, state and local laws and regulations pertaining to labor standards insofar as and when those acts apply to the performance of this Agreement. The Subrecipient agrees to comply with the Copeland Anti -Kick Back Act (18 U.S.C. 874 et seq.) and the implementing regulations thereto issued by the U.S. Department of Labor at 29 CFR Part 5. The Subrecipient shall maintain documentation that demonstrates compliance with applicable hour and wage requirements. 18-6746/ 185 722/mv 19 (c) Prevailing Wage. The Subrecipient agrees that, to the extent applicable, all contractors engaged under contracts for construction, renovation or repair work financed in whole or in part with assistance provided under this Agreement shall comply with the regulations of the Department of Labor, under 29 CFR Parts 1, 3, 5 and 7 and California Labor Code Section 1720, et seq. governing the payment of wages and ratio of apprentices and trainees to journey workers. The Subrecipient shall cause or require to be inserted in full, in all such contracts subject to such regulations, provisions meeting the requirements of this paragraph. (d) Section 3 Clause. The Subrecipient agrees, to the extent applicable, to comply with Section 3 of the HUD Act of 1968, as amended, and as implemented by the regulations set forth in 24 CFR 135. 6.4 Conduct. (a) Assignment. The Subrecipient shall not assign or transfer any interest in this Agreement without the prior written consent of the City thereto; provided, however, that claims for money due or to become due to the Subrecipient from the City under this Agreement may be assigned to a bank, trust company, or other financial institution without such approval. Notice of any such assignment or transfer shall be furnished promptly to the City. (b) Subcontracts. (i) Approvals. The Subrecipient shall not enter into any subcontracts with any entity, agency or individual in the performance of this Agreement without the written consent of the City prior to the execution of such agreement. (ii) Monitoring. The Subrecipient will monitor all subcontracted services on a regular basis to assure contract compliance. Results of monitoring efforts shall be summarized in written reports and supported with documented evidence of follow-up actions taken to correct areas of noncompliance. (iii) Content. The Subrecipient shall cause all of the provisions of this Agreement in its entirety to be included in and made a part of any subcontract executed in the performance of this Agreement. (iv) Selection Process. The Subrecipient shall undertake to insure that all subcontracts let in the performance of this Agreement shall be awarded on a fair and open competition basis in accordance with 18-6746/185722/mv 20 applicable procurement requirements. Executed copies of all subcontracts shall be forwarded to the City along with documentation concerning the selection process. (c) Hatch Act. The Subrecipient agrees that no funds provided, nor personnel employed under this Agreement, shall be in any way or to any extent engaged in the conduct of political activities in violation of Chapter 15 of Title V of the U.S.C. (d) Conflict of Interest. The Subrecipient agrees to abide by the provisions of 24 CFR 84.42 and 92.356, which include (but are not limited to) the following: (i) The Subrecipient shall maintain a written code or standards of conduct that shall govern the performance of its officers. employees or agents engaged in the award and administration of contracts supported by HOME Funds. (ii) No employee, officer or agent of the Subrecipient shall participate in the selection, or in the award, or administration of, a contract supported by HOME Funds if a conflict of interest, real or apparent, would be involved. (ill) No covered persons who exercise or have exercised any functions or responsibilities with respect to HOME -assisted activities, or who are in a -position to participate in a decision -making process or gain inside information with regard to such activities, may obtain a financial interest in any contract, or have a financial interest in any contract, subcontract, or agreement with respect to the HOME - assisted activity, or with respect to the proceeds from the HOME - assisted activity, either for themselves or those with whom they have business or immediate family ties, during their tenure or for a period of one (1) year thereafter. For purposes of this paragraph, a "covered person" includes any person who is an employee, agent, consultant, officer, or elected or appointed official of the City, the Subrecipient, or any designated public agency. (e) Lobbying. The Subrecipient hereby certifies that: (i) No federal appropriated funds have been paid or will be paid, by or on behalf of it, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal 1 oan, the entering into of any cooperative agreement, 18-6746/185722/mv 21 and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement; (ii) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, it will complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions; and (iii) It will require that the language of paragraph (iv) of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all Subrecipients shall certify and disclose accordingly. (f) Lobbying Certification. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352 Title 31, US.C. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. (g) Religious Activities. The Subrecipient agrees that funds provided under this Agreement will not be utilized for inherently religious activities such as worship, religious instruction, or proselytization. ARTICLE 7 GENERAL CONDITIONS 7.1 General Compliance. The Subrecipient agrees to comply with the requirements of the HOME Program in the administration and implementation of the TBRA Program and this Agreement. The Subrecipient shall carry out each activity in compliance with all regulations described in- subpart H of 24 CFR Part 92, except that the Subrecipient does not assume the City's responsibilities for environmental review under 24 CFR 92.352 and the intergovernmental review process described in 24 CFR 92.357 does not apply to the Subrecipient. The Subrecipient also agrees to comply with all other applicable federal, state and local laws, regulations, and policies governing the funds provided under this Agreement. The Subrecipient further agrees to utilize funds available under this Agreement to supplement rather than supplant funds otherwise available. 18-6746/185722/mv 22 7.2 Familiarity with Services; Qualified Personnel. (a) By executing this Agreement, Subrecipient represents and warrants that Subrecipient (i) has thoroughly investigated and considered the Services to be performed, (ii) has carefully considered how the Services should be performed, and (Ili) fully understands the requirements, difficulties and restrictions attending the performance of the Services under this Agreement. (b) Subrecipient represents that Subrecipient has or will secure and maintain, at Subrecipient's sole cost and expense, all qualified and licensed personnel required to perform the Services. Staff and any additional personnel hired by Subrecipient shall be employees of Subrecipient. Such personnel shall not be deemed to be employees of City or to have any contractual relationship with City. Such Personnel shall be authorized or permitted under state and local law to perform the Services. 7.3 Independent Contractor. In performing under this Agreement, Subrecipient is and shall at all times be acting and performing as an independent contractor to City, performing its duties in accordance with its own judgment. City shall neither have nor exercise _any control or direction over the methods by which Subrecipient performs its work and function nor shall City have the right to interfere with such freedom or action or prescribe rules or otherwise control or direct the manner in which such services are performed. The sole interest of the City in the Services performed by the Subrecipient is that such Services be performed in a legal competent, efficient and satisfactory manner. Nothing contained herein shall cause the relationship between the parties to this Agreement to be that of employer and employee. Subrecipient shall not have the authority to obligate City to any contract, obligation, or undertaking whatsoever and shall make no representation, either oral or in writing. 7.4 Subrecipient Representative. Subrecipient hereby designates Patti Long, Operations Director as its Project Manager for the TBRA Program ("Subrecipient's Representative"). Subrecipient's Representative shall supervise and direct the Services, using his or her best skill and attention, and shall be responsible for all means, methods, techniques, sequences and procedures and for the satisfactory coordination of all portions of the Services under this Agreement. 7.5 Nepotism. Subrecipient shall not hire or permit the hiring of any person to fill a position funded through this Agreement if a member of the person's immediate family is employed in an administrative capacity by City's HOME Program or any department of the City which is administering the HOME Program. For the purposes of this section, the term "immediate- family' means spouse, child, mother, father brother, sister, brother-in-law, sister-in-law, father-in-law, mother- in-law, son-in-law, daughter-in-law, aunt, uncle, stepparent and stepchild. The 18-6746/185722/mv 23 term "administrative capacity" means having selection, hiring, supervisory or management responsibilities, including serving on the governing body of City. 7.6 Hold Harmless. The Subrecipient shall indemnify, hold harmless, and defend the City and their elected officials, officers, employees and agents and shall pay for expenses incurred by the City for any and all claims, actions, suits, charges and judgments whatsoever related in any manner to or that arise out of the Subrecipient's performance or nonperformance of the Services or subject matter called for in this Agreement. 7.7 City Recognition. The Subrecipient shall insure recognition of the role of the City in providing Services through this Agreement. All activities, facilities and items utilized pursuant to this Agreement shall be prominently labeled as to funding source. 7.8 Notices. Any approval, disapproval, demand, document or other notice ("Notice") which any party may desire to give to the other party under this Agreement must be in writing and may be given either by (i) personal service, (ii) delivery by reputable document delivery service such as Federal Express that provides a receipt showing date and time of delivery, (iii) facsimile transmission, or (vi) mailing in the United States mail, certified mail, postage prepaid, return receipt requested, addressed to the address of the party as set forth below, or at any other address as that party may later designate by Notice. Service shall be deemed conclusively made at the time of service if personally served; upon confirmation of receipt if sent by facsimile transmission; the next business if sent by overnight courier and receipt is confirmed by the signature of an agent or employee of the party served; the next business day after deposit in the United States mail, properly addressed and postage prepaid, return receipt requested, if served by express mail; and three (3) days after deposit in the United States mail, properly addressed and postage prepaid, return receipt requested, if served by certified mail. Subrecipient: Larry Haynes Executive Director Mercy House PO Box 1_905 Santa Ana, CA 92702 City: City Clerk City of Huntington Beach 2000 Main Street Huntington Beach, CA 92648 18-6746/185722/mv 24 With copies to: Kellee Fritzal Office of Business Development 2000 Main Street Huntington Beach, CA 92648 Such addresses may be changed by Notice to the other party(ies) given in the same manner as provided above. 7.9 Amendment and Waiver. This Agreement may be amended, modified, or supplemented only by a writing executed by each of the parties. Any party may in writing waive any provision of this Agreement to the extent such provision is for the benefit of the waiving party. No action taken pursuant to this Agreement, including any investigation by or on behalf of any party, shall be deemed to constitute a waiver by that party or its or any other party's compliance with any representations or warranties or with any provision of this Agreement. 7.10 Entire Agreement. This Agreement, including all Exhibits attached hereto, embodies the entire agreement and understanding between the parties pertaining to the subject matter of this Agreement and supersedes all prior agreements, understandings, negotiations, representations, and discussions, whether verbal or written, of the parties pertaining to the subject matter. In the event of a conflict between this Agreement, on one hand, and any Exhibit attached hereto, on the other hand, the provisions of this Agreement shall control; provided, if it is possible to comply with the requirements of this Agreement and the Exhibits, the parties shall do so. The following Exhibits are attached to this Agreement and incorporated herein: Exhibit A TBRA Program Operating Guidelines Appendix Al LA-OC Collaborative HMIS Intake Form —General Appendix A2 HMIS Consent Form Appendix A3 Disclosure Consent Form Appendix A4 Release of Information Authority Appendix A5 Household Obligation & Responsibilities Appendix A6 Declaration of Alternate Housing Attempts Appendix B TBRA Application Appendix CI Declaration of Homelessness Appendix C2 At -Risk Declaration Appendix D Rental Assistance Contract Appendix E Landlord Sub Agreement Appendix F Program Lease Addendum 18-6746/185722/mv 25 Appendix G Rent Reasonableness and Fair Market Rent Certification Appendix H Orange County Housing Authority Utility Allowance Schedule Appendix I Case Management Policies and Procedures Exhibit B Documentation, Recordkeeping, Reporting and Monitoring Requirements Exhibit C Gross Income Calculation Form Exhibit D Household Budget Worksheet Exhibit E Lead -Based Hazard Information Pamphlet "Protect Your Family from Lead in your Home" Exhibit F Budget Exhibit G Housing Quality Standards (HQS) Inspection Checklist 7.11 Governing Law. The validity, construction, and performance of this Agreement shall be governed by the laws of the State of California. 7.12 Non -Liability of Members, Officials and Employees of City. No member, official or employee of City shall be personally liable to Subrecipient, or any successor in interest, in the event of any Default or breach by City or for any amount which may become due to Subrecipient or Subrecipient's successors, or on any obligation under the terms of this Agreement. Subrecipient hereby waives and releases any claim Subrecipient may have against the member, officials or employees of City with respect to any Default or breach by City or for any amount which may become due to Subrecipient or Subrecipient's successors, or any obligations under the terms of this Agreement. Subrecipient makes such release with the full knowledge of Civil Code Section 1542 and hereby waives any and all rights thereunder to the extent of this release, if such Section 1542 is applicable. Section 1542 of the Civil Code provides as follows: "A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR." l 8-6746/185722/mv 26 ARTICLE 8 ENFORCEMENT; TERMINATION 8.1 Events of Default. (a) For purposes of this Agreement, the word "Default" shall mean the failure of Subrecipient to perform any of Subrecipient's duties or obligations or the breach by Subrecipient of any of the terms and conditions set forth in this Agreement; any failure by Subrecipient to comply with any of the rules, regulations or provisions referred to herein, or such statutes, regulations, executive orders, and HUD guidelines, policies or directives as may become applicable at any time; any ineffective or improper use of funds provided under this Agreement; or submission by the Subrecipient to the City reports that are incorrect or incomplete in any material respect. In addition, Subrecipient shall be deemed to be in Default upon Subrecipient's (i) application for, consent to, or suffering of, the appointment of a receiver, trustee or liquidator for all or a substantial portion of its assets, (ii) making a general assignment for the benefit of creditors, (iii) being adjudged bankrupt, (iv) filing a voluntary petition or suffering an involuntary petition under any bankruptcy, arrangement, reorganization or insolvency law (unless in the case of an involuntary petition, the same is dismissed within thirty (30) days of such filing), or (v) suffering or permitting to continue unstayed and in effect for fifteen (15) consecutive days any attachment, levy, execution or seizure of all or a substantial portion of Subrecipient's assets or of Subrecipient' s interests hereunder. (b) City shall not be deemed to be in Default in the performance of any obligation required to be performed by City hereunder unless and until City has failed to perform such obligation for a period of thirty (30) days after receipt of written notice from Subrecipient specifying in reasonable detail the nature and extent of any such failure; provided, however, that if the nature of City's obligation is such that more than thirty (30) days are required for its performance, then City shall not be deemed to be in Default if City shall commence to cure such performance within such thirty (30) day period and thereafter diligently prosecute the same to completion. 8.2- Institution of Legal Actions. In addition to any other rights and remedies, and subject to the restrictions otherwise set forth in this Agreement, either party may institute an action at law or in equity to seek the specific performance of the terms of this Agreement, to cure, correct or remedy any Default, to recover damages for any Default or to obtain any other remedy consistent with the purpose of this Agreement. Such legal actions must be instituted in the Superior Court of the County of California, State of California or in the United 18-6746/185722/mv 27 States District Court for the Central District of California. 8.3 Acceptance of Service of Process. In the event that any legal action is commenced by the Subrecipient against City, service of process on City shall be made by personal service upon the City Clerk or in such other manner as may be provided by law. In the event that any legal action is commenced by City against the Subrecipient, service of process on the Subrecipient shall be made by personal service upon Subrecipient's Representative or in such other manner as may be provided by law. 8.4 Rights and Remedies Are Cumulative. Except as otherwise expressly stated in this Agreement, the rights and remedies of the parties are cumulative, and the exercise by either party of one or more of such rights or remedies shall not preclude the exercise by it, at the same or different times, of any other rights or remedies for the same Default or any other Default by the other party. 8.5 Inaction Not a Waiver of Default. Any failures or delays by either party in asserting any of its rights and remedies as to any Default shall not operate as a waiver of any Default or of any such rights or remedies, or deprive either such party of its right to institute and maintain any actions or proceedings which it may deem necessary to protect, assert or enforce any such rights or remedies. 8.6 Attorney's Fees. City and Subrecipient agree that in the event of litigation to enforce this Agreement or terms, provisions and conditions contained herein, to terminate this Agreement, or to collect damages for a Default hereunder, the prevailing party shall not be entitled to costs and expenses, including reasonable attorney's fees, incurred in connection with such litigation, such that each party shall be responsible for their costs and attorneys' fees. 8.7 Termination. (a) Termination for Cause. In accordance with 24 CFR 85.43, the City may suspend or terminate this Agreement in the event of a Default by the Subrecipient under this Agreement. Subrecipient may suspend or terminate this Agreement if City fails to make payments to Subrecipient as required herein. (b) Termination for Convenience. In accordance with 24 CFR 85.44, this Agreement may also be terminated for convenience by either the City or the Subrecipient, in whole or in part, by setting forth the reasons for such termination, the date the termination will be effective, and, in the case of partial termination, the portion to be terminated. However, if in the case of a partial termination, the City determines that the remaining portion of the award will not accomplish the purpose for which the award was made, the City may terminate the award in its entirety. 18-6746/185722/mv 28 IN WITNESS WHEREOF, the parties have executed this HOME Recipient Agreement (Tenant Based Rental Assistance) as of the Effective Date, which is the date of the City Council approving this Agreement. SUBRECIPIENT: MERCY HOUSE, a California nonprc By: CITY: CITY OF HUNTINGTON BEACH, corporation a municipal corporation and charter city print name ITS: Executive Director AND B. print ame ITS (cirrle_one) Secretary/ Chief Financial Office Asst. Secretary — Treasurer COUNTERPART By: City Manager ATTEST: By: City Clerk APPROVED AS TO FORM: By: City Attorney µ✓ INITIATED AND APPROVED: By: Deputy Director of Economic Development REVIEWED AND APPROVED: By: Assistant City Manager 18-6746/ 185722/mv 29 IN WITNESS WHEREOF, the parties have executed this HOME Recipient Agreement (Tenant Based Rental Assistance) as of the Effective Date, which is the date of the City Council approving this Agreement. SUBRECIPIENT: MERCY HOUSE, a California nonprofit corporation By: print name ITS: Executive Director AND By: CITY: CITY OF HUNTINGTON BEACH, a municipal c rporation and charter city By: 997,"— CiffNIA,ger ATTEST: Q By: 4�7� [�� City Clerk /c%H /p bs APPROVED AS T print name ITS: (circle one) Secretary/ By: Chief Financial Officer/Asst. Secretary — Treasurer COUNTERPART Attorney µv INITXATED AN-D APPROVED: By: xe�� Deputy Directo Economic Development REVIEW D AA�2�ROVED: By: OTA�� Assistantager 18-6746/ 185722/mv 29 Mercy House Exhibit A TBRA Operating Guidelines City ®f Huntington Beach Tenant -Based Rental Assistance Program Operating Guidelines I. Program Overview The City of Huntington Beach (City) has established a Tenant -Based Rental Assistance (TBRA) program (Program) that follows all the requirements of the HOME Program, as set forth in the HOME Program under Section 24, Part 92, of the code of Federal Regulations (24 CFR 92). In 2016, the City published a Request for Proposals (RFP) and selected Mercy House to administer the Program through 2020. The City will evaluate the impact of the Program on homeless individuals and families at the end of the term to determine the merits of extending the program and the effectiveness of the services provided by Mercy House. Key indicators of success will include the ability to transition off the Program and remain housed without assistance for at least six months, increases in earned income, and sustainable rent burden (at or below 30% of family income). The Program will provide short and medium -term rental assistance was well as housing relocation and stabilization services for homeless and at -risk of homeless households from Huntington Beach, who have extremely -low income. All at -risk of homeless households shall be approved by the Deputy Director of Business Development. The Program will meet the City's Investment Criteria by targeting program assistance to 34 homeless or at -risk households, all with incomes at or below 30% AMI and preference given to veterans, seniors and victims of domestic violence. Mercy House's services will primarily be targeted to households without children. The procedures set forth herein establish the tenant selection guidelines for the Program, provide the necessary operating structure for the Program and clarify the roles and responsibilities of Mercy House and the City. II. Marketing, Outreach and Application Process A. Marketing and Outreach Mercy House is responsible for marketing and outreach activities to find prospective Eligible Households interested in the Program. Mercy House will conduct community presentations, outreach, training to community organizations, and participate in community events to educate on TBRA resources available. Additionally, Mercy House will continue to partner with Huntington Beach Police Department, OC211, Huntington Beach Homeless Task Force, and other housing providers to refer eligible residents of Huntington Beach eligible for TBRA assistance. Due to limitations on the type and scope of assistance that may be provided with TBRA funds, clients who are referred to the program must have income or have the ability to gain employment. Mercy House will provide quarterly reports to the City that shall describe the marketing and outreach efforts for the quarter. All marketing need to be done to meet all affirmative marketing requirements. B. Waiting List Once the Program has reached maximum enrollment, estimated at 34 households over the 2-year contract period, Mercy House shall maintain a waiting list of prospective Eligible Households. This list will be prioritized as follows: ■ Clients who have been assessed for TBRA eligibility, completed intake process, and ready for housing placement. ■ Clients who have been assessed for TBRA eligibility, completed intake process, and searching for housing. ■ Clients who have been assessed for TBRA eligibility and pending intake. ■ Ready for housing placement means that the household has found a housing unit that meets TBRA requirements (many landlords won't accept third party payments, rent requested by landlord is too high, won't allow unit inspection, etc.) ■ Priority ranking will be given for Homeless Category 1 (24 CRF 91, 582 and 583) - literally homeless participants will come from the streets or other locations not meant for human habitation, emergency shelters, or safe havens. Targeted preference will be given to veterans, seniors, and victims of domestic violence (Homeless Category 4) to support the City's investment priorities. Within these categories, households will be helped on a first come — first served basis, based on the date and time of application completed. C. Intake Process As part of the intake process, Mercy House will meet with the prospective Eligible Household to conduct a needs assessment and complete an Initial Qualifications Form (Appendix A). If the Program has reached maximum capacity, Mercy House shall review the applicant to assess if other services may be offered while the applicant is waiting for a slot to open in the Program. As part of the intake process, Mercy House shall also request and/or assist the prospective Eligible Household with the completion of the following documents: ■ TBRA Application (Appendix B) ■ Declaration of Homeless Status or Declaration of At -Risk of Homelessness Status (Appendix C) D. Guidance for Eligible Households Mercy House will meet with the prospective Eligible Households throughout the application process and will continue to meet with and counsel each Eligible Household regarding the Program, the Eligible Household's responsibilities as participants of the Program, and the goals and objectives of the Program. III. Determination of Eligibility The Program will utilize HOME Program funds for supportive services and rental assistance. As such, the applicants must meet the eligibility qualifications of the HOME Program. Eligibility for services offered by the Program shall adhere to the following selection criteria: A. Income Eligible Households ■ To receive supportive services as well as rental assistance under the HOME Program, the Applicant's total household income must be at or below 30% of the Orange County area median income (AMI). However, once the Applicant is part of the Program, the household income can increase up to 80% of the AMI before Mercy House must give notice of termination from the Program. ■ Income limits for extremely -low income households are established annually for the HOME Program by HUD for the Orange County income limit area. ■ Gross Annual Income shall be determined in accordance with 24 CFR 5.609, with the allowable exclusions from income established at 24 CFR 5.611. ■ Gross Annual Income means the gross amount of income from all sources, including assets, for all adult household members that is anticipated to be received prospectively during the 12-month period following the date of application and before any deductions are taken. ■ Mercy House will determine and verify eligibility for assistance under the Program through the review of income source documents. As outlined in the revised HOME rules published in July 2013, applicants must provide evidence of income for the two (2) most recent months. Acceptable source documents include wage statements, check stubs, entitlement verification from another government agency and bank statements. The definition of income for the purposes of the Program is located at 24 CFR Part 5 (often referred to as the Section 8 definition). In cases where no evidence of income (third -party verification) is available, Mercy House may allow clients to self -report their income. In such cases, Mercy House staff will provide a written explanation for why they were unable to obtain third -party verification or documentation. ■ Mercy House may also consider any likely changes in income when collecting income verification documentation. ■ Initial income verifications are valid for six months. If admission to the Program takes longer than 6 months, income verifications must be updated and reevaluated. After initial verification, income recertification shall be conducted annually. ■ Income verifications will be used for two purposes: To determine eligibility for services. A determination of eligibility will be completed as part of the admissions process and thereafter annually. Income information will be used to establish the household's initial contribution toward rent, which shall be set at 30% of the household income. The household's initial contribution will remain unchanged for at least six months. B. Current Residents of the City of Huntington Beach Due to the nature of the population served by the Program, it may not be possible to obtain traditional proof of residency documentation such as utility bills. The following documentation can be accepted to establish that an applicant household qualifies for the Huntington Beach live/work preference: ■ Documentation from a Huntington Beach school that the children in the household have been enrolled in and attending the school for at least the last 90 days from the time of admission into the Program. ■ Documentation from a partner agency, such as the Huntington Beach Police Department, evidencing that the family is known to be homeless in Huntington Beach. ■ Proof that the applicant's last place of stable residency was in the City of Huntington Beach. Verification from a landlord is acceptable. ■ Proof that an adult member of the household is working or has been recently hired to work in Huntington Beach. C. Currently Homeless or At -Risk of Homelessness ■ At -Risk of Homelessness refers to a household that is at imminent risk of being evicted due to an economic hardship in paying rent or staying current with rent. (Category 2 of HUD Homeless Definition) ■ Homelessness refers to a household who meets the HUD Homeless Definition at 24 CRF 91, 582 and 583: Category 1 (literally homeless) and Category 4 (fleeing/attempting to flee violence and living in a place described in Category 1). D. Preferences The following summarizes the populations that Mercy House will target (note that the total percentages do not total to 100%): Veterans 14% seniors 14% Homeless 100% E. Annual Eligibility Verification Mercy House will requalify each Eligible Household, including examination of source documentation, on an annual basis. Mercy House may request that a participating Eligible Household provide verification(s) more often than annually, as reasonably necessary to confirm continued qualification and eligibility for the Program. ■ Mercy House will provide written notice to each applicant stating whether the Eligible Household was determined to be eligible for continued assistance under the Program. IV. Selection of Housing A. Housing Unit Selection Eligible Households must be residents of Huntington Beach and may elect to rent any Housing Unit in the City so long as the unit meets federal housing quality standards (HQS) or such other standards as may be made applicable to the Program by HOME Program statues and/or regulations, specifically including Uniform Physical Condition Standards (UPCS) and passes a rent reasonableness test. Due to the nature of the population served by the Program, it is expected that Mercy House will assist Eligible Households with finding and selecting an appropriate Housing Unit that meets all program requirements. If an appropriate Housing Unit cannot be located within the City boundaries, a Housing Unit can be located outside of the City boundaries when housing is not suitable within City boundaries While Mercy House can refer Eligible Households to appropriate Housing Units, households may not be required to select a particular Housing Unit. Rental assistance under the Program is only provided for Housing Units that meet the criteria established by the City of Huntington Beach HOME/TBRA Program. B. Occupancy Standards The number of persons in each Eligible Household will determine the required unit type. Each household must comply with the two per bedroom plus one occupancy standard. The following table provides the occupancy standards by unit type: One -bedroom Unit Up to 3 Persons Two -bedroom Unit Up to 5 Persons Three -bedroom Unit Up to 7 Persons Four -bedroom Unit Up to 9 Persons C. Property Inspections Prior to occupancy of any Housing Unit by an Eligible Household, and again during the annual verification process, Mercy House will have a certified HQS inspector, inspect each Housing Unit to ensure the unit complies with HQS as set forth in the HOME Program (24 CFR 92.251), as well as all applicable state and local codes and ordinances, including zoning ordinances. Each HQS inspection will include the following: ■ Verification of the age of the Housing Unit (on Rent Reasonableness Form); ■ Completed HQS Inspection Form (HUD-52580); ■ Lead -based paint hazard assessment, dissemination of lead -based paint information pamphlet and disclosure form and lead -based paint reduction activities, if required; ■ Adequate opportunity for landlord to correct any deficiencies indicated in the HQS Inspection form to bring the Housing Unit into compliance; and Verification that occupancy by the Eligible Household will comply with occupancy standards. The HQS Inspection Form is located in Appendix D. D. Rent Reasonableness Rental assistance paid on behalf of the Eligible Household must be in compliance with federal Rent Reasonableness requirements which require that rents paid by or on behalf of assisted households be similar to rents paid by non -assisted households. Rent Reasonableness reviews will be performed by Mercy House. The factors listed below shall be considered when determining rent comparability: ■ Location and age; ■ Unit size including the number of rooms and square footage or rooms; The type of unit including construction type (e.g., single family, duplexes, garden, low-rise, high- rise); ■ The quality of the unit, which includes the building construction, maintenance and improvements; and ■ Amenities, services and utilities included in the rent. Mercy House will follow both the rent reasonableness regulations established for the Housing Choice Voucher (HCV) program at 24 CFR 982.507 to evaluate rents. In the event that a rent request does not meet rent reasonableness requirements, Mercy House shall attempt to negotiate a lower rent with the property owner. If the owner is not willing to accept a lower rent, the household must be instructed to search for another unit. Under no circumstances shall Mercy House or the assisted household agree to pay more than approved through the rent reasonableness review. Additionally, the assisted household is not allowed to make up any difference in the rent offer. E. Coordination with Landlords Mercy House will meet with and provide guidance to landlords participating in the Program regarding the requirements and procedures that impact landlords. i. Landlord Agreement (Appendix E) ■ Mercy House will enter into a Landlord Agreement with each participating landlord or property owner. The Landlord Agreement will establish the security deposit assistance payment and the initial rental assistance payments to be paid on behalf of the household. The Agreement will also establish the participating household's initial share of the contract rent. The Agreement will also require the landlord to provide Mercy House with notice of a lease termination, and reaffirm the tenant protections included in the Tenant Protection Agreement. ■ The Eligible Household's share of rent will be re-evaluated every 6 months. ■ This contract will have an initial term of 12 months. ii. Tenant Protection Agreement (Appendix F) ■ The landlord will be required to enter into a lease agreement with a term of 12 months with any Eligible Household occupying a Housing Unit. ■ The lease agreement will include a Tenant Protection Agreement that will be executed in connection with the lease between the landlord and the Eligible Household. ■ The Tenant Protection Agreement will include the following elements: ■ Prohibit the inclusion of the following provisions in the lease, as required by 24 CFR 92.253: ■ (1) Agreement to be sued; ■ (2) Treatment of property; ■ (3) Excusing owner from responsibility; ■ (4) Waiver of notice; ■ (5) Waiver of legal proceedings; ■ (6) Waiver of a jury trial; ■ (7) Waiver of right to appeal court decision; ■ (8) Tenant chargeable with cost of legal actions regardless of outcome; and 0 (9) Mandatory supportive services. ■ Confirm the landlord's obligation to maintain the Housing Unit in accordance with HQS, as established at 24 CFR 982.401. ■ Prohibit discrimination by the landlord against the Eligible Household. e Mercy House will review the lease agreement to confirm its compliance with state law and all HOME Program requirements. V. Payment Standards, Rent Calculation, Term and Subsidy Reductions As authorized by HOME TBRA regulations, the Program will rely on a traditional rental assistance calculation. The model allows for the rent subsidy determination based on 30% of household income. A. Rent Assistance Calculation Mercy House will complete a rental assistance calculation for each Eligible Household. The calculation will determine each household's Program subsidy and share of the rent. The maximum amount of monthly assistance that Mercy House may pay on behalf of a family is the difference between the rent standard for the unit size and 30% of the household's monthly adjusted income. Each household's maximum rent subsidy will vary since the calculation involves the use of individualized factors such as the household's actual income and family size. The initial household contribution to rent will remain unchanged for at least six months. Minimum tenant contribution to rent under the Program is set at $50.00. This minimum is used if the maximum subsidy calculation would result in the household paying less than $50.00 towards the monthly rent (e.g. if 30% of the household's monthly adjusted income is less than $50.00). This minimum contribution may be waived in exceptional circumstances. B. Rent Reasonableness Standards The Program must use the Rent Reasonableness Standard (Appendix G) to calculate monthly rental assistance. j[AD1]The payment standards represent the cost of rent and utilities for moderately priced units in Huntington Beach as well as those in surrounding Orange County cities Payment standards are established by bedroom size. When utilities are included in the cost of renting a unit, that is, the owner assumes responsibility for payment for all utility services, the household's entire share of the housing costs will go directly to the owner. When the cost of utilities is not part of the rent, that is, the household is directly responsible for payment of utility services, the household's initial share will be determined by subtracting a utility allowance from 30% of the household's income. Mercy House must use the Orange County Housing Authority utility allowance schedule (Appendix H) to determine the household's utility allowance. In these cases, the household's share of the rent is equal to 30% of the household's monthly adjusted income minus the applicable monthly utility allowance. Each household is responsible for paying their rent share directly to the landlord each month. If a selected Housing Unit is subject to contractual, statutory and/or regulatory affordability restriction, the monthly rental assistance payments will not exceed the difference between the required affordable rent amount for the Housing Unit and 30% of the Eligible Household's monthly adjusted income. i. Participant Agreement (Appendix J) Mercy House will enter into a Participant Agreement with each participating client household. The Participant Agreement will establish the Eligible Household's responsibilities towards rent payments. The Agreement will establish the participating household's initial share of the contract rent, which will be adjusted every 6 months. ii. Term Mercy House will provide rental assistance for an initial term of 6 months, which can be extended every 6-12 months, for a cumulative term of up to 24 months. Extensions will be granted at the discretion of Mercy House and shall be based on continued Program compliance and ongoing need. Mercy House will utilize the Gap Analysis and Income Re -Evaluation to assess ongoing need and adjust household's share of rent as appropriate. Households with income above 60% AMI will be notified about income eligibility limits. iii. Subsidy Reductions The participant's household income will be reevaluated every six months. If the household income has increased since the previous evaluation, the participant's monthly rent responsibility will be adjusted accordingly per Rent Assistance Calculation as stated in above section V. A. VI. Security Deposits As needed, Mercy House will provide security deposit assistance to Eligible Households. Such assistance shall be the lesser of: Two months approved rent for the Housing Unit; or ■ The standard security deposit required by the landlord for non -subsidized tenants. Security deposit assistance provided to participating households will be in the form of a grant. As such, the landlord can provide a security deposit refund directly to the household. Any disputes involving the return, or lack thereof, of a security deposit shall be settled by the tenant and landlord, as provided for in the lease. VII. Utility Deposits As needed, Mercy House will provide utility deposit assistance to Eligible Households. Utility deposit assistance provided to participating households will be in the form of a grant. As such, the utility provider can provide a utility deposit refund directly to the household. Any disputes involving the return, or lack thereof, of a utility deposit shall be settled by the tenant and the utility provider. The Utility deposit subsidies cannot be used as a stand-alone activity. The assistance must be utilized with rental subsidy, security deposit subsidy, or both. VIII. Annual Recertification, Termination of Assistance and Returning Households A. Annual Recertification Recertification of income and Program eligibility will occur annually. Mercy House will gather source documentation for participating households to determine annual income. Annual income must be calculated in accordance with 24 CFR Part 5. If the total household income is above 80% AMI, rental assistance must be terminated following a 30 day notification period. B. Termination of Rental Assistance Assistance can be terminated for the following reasons: ■ Eviction from the assisted rental unit based on behavioral issues and/or unlawful activity. ■ The family will be assisted by another rental assistance program such as the Section 8 Tenant -Based or Project -Based program. Participation in any other rental assistance program is considered a duplicative subsidy therefore all HOME funded rental assistance must terminate. C. Returning Participant Households As needed, participants may be allowed to return to the Program for either support services, rental assistance or both. A determination to allow re-entry shall be based on the following criteria: ■ Participants must have left the Program in good standing. To be in good standing, participants must have been engaged in their case management plan, voluntarily left the program (not in -lieu of termination) or have been released because their household income exceeded eligible limits. In general, participants will not be allowed to re-enter the Program if they were terminated for non- compliance. ■ At the discretion of Mercy House, a request for readmission from a non -compliant household may be considered when compelling reasons exist. In such cases, re -admission will require concurrence from the City. ■ The Participant's previous rental assistance did not exceed 24 months. Cumulatively, participants will only be allowed to receive rental assistance for a maximum of 24 months. IX. Self Sufficiency Program Mercy House will request each Eligible Household receiving rental assistance payments to participate in a Self -Sufficiency Program administered by Mercy House. The Case Management and Self -Sufficiency Program Policies and Procedures are outlined in Appendix J. The Self -Sufficiency Program provides participating households with intense case management, which is designed to assist participants move to self-sufficiency within a 12 to 24-month period. Income recertifications will be completed annually for participating households. If the participating household's income exceeds the low (80% AMI) income limits, Mercy House must terminate the rental assistance. Listed below are some of the Self -Sufficiency Case Management Services offered by Mercy House: A. Case Management The Mercy House Case Management model maximizes client success by developing individualized service plans and addressing clients' specific needs in securing permanent housing and self-sufficiency. Clients will meet with their Case Manger on a minimum of a monthly basis to update goals, monitor progress, and ensure long-term housing stability. Self-sufficiency groups are also held weekly to assist with financial management, job development, life skills, personal empowerment, and accessing other resources needed to gain housing stability. B. Individualized Housing and Service Plan Participants meet with their Case Manager at intake and monthly to review their Goal Worksheet and Individualized Service Plan to help establish and identify participant goals and plans for housing, education, employment, financial (including budgeting and credit repair), legal, and other housing stabilization and relocation resources needed. C. Housing Search and Placement Mercy House advocates assists clients with comprehensive housing search and placement into affordable permanent housing. Mercy House has established close partnerships with permanent housing agencies, including affordable housing providers, apartment associations, and private landlords/owners. D. Legal Services Staff attorneys, legal advocates and volunteer attorneys provide comprehensive legal services and representation in multiple languages. Legal assistance includes lease agreements, legal advocacy, court accompaniment, and other legal issues affecting homeless and at -risk homeless persons and their children. E. Financial Management / Credit Repair Mercy House assists program participants with credit repair, financial literacy, and job placement and retention. Assistance will also be provided to access mainstream financial benefits including social security, veteran's benefits, CaIWORKs, disability, unemployment, and other public assistance. F. Employment Assistance Obtaining self-sufficiency is a critical goal forfamilies served by Mercy House. Mercy House Case Managers work with clients to identify interests, life experiences and talents that lend themselves to employment. Housing Advocates also: Help clients develop resumes, complete job application and prepare for interviews; Obtain educational scholarships through AmeriCorps and other sources to increase leadership skills and/or further their education; ■ Provide transportation solutions to job interviews and job -related activities; and ■ Provide job placement in career -level jobs and job retention assistance. G. Transportation Mercy House provides support services at Community Service Center and Satellite sites in Huntington Beach conveniently accessible via public transportation routes or via home visits as needed. Mercy House provides assistance with transportation via bus passes and accessing mainstream resources available for transportation through CalWORKs and disability access. Mercy House also maintains agreements with local taxi companies to provide emergency transportation assistance and works closely with the Huntington Beach Police Department to assist transport participants in crisis situations. H. Behavioral Health Mercy House provides an array of individual and group counseling programs on -site and works closely with other mental health providers to address behavioral health needs of participants. Appendices Appendix A Initial Qualification Form (MH) Appendix B TBRA Application Form (MH) Appendix C Declaration of Homelessness Status (MH) Appendix D Rental Assistance Contract (MH) Appendix E Landlord Agreement (MH) Appendix F HOME Program Lease Addendum (MH) Appendix G Rent Reasonableness and Fair Market Rent Certification (MH) Appendix H Utility Allowance Chart (MH) Appendix I Case Management & Self -Sufficiency Program Policies and Procedures (MH) Mercy House Exhibit A — Appendix Al LA-OC Collaborative HMIS Intake From - General HMIS Intake and Enrollment Form - General Client Name/ ID: HMIS consent? ❑ No (refused) ❑ Signed Consent Form First Name: Last Name: Middle Name (Optional): Suffix (Optional): Name Data Quality: Physical Description (Optional): Last Known Permanent Address: Did the client provide their full Where have you last lived for 90 days or more? name? Not including emergency shelters and transitional housin Full Name Reported Address: _ Partial, street name, or code City: name reported -i Client Doesn't Know County: - Client Refused Data not Collected Date of Birth: SSN: State: - - Full SSN reported -- Full DOB reported Approximate or partial DOB - Approximate or partial SSN Zip: reported reported Client Doesn't Know - Client Doesn't Know Address ❑ Full address reported ❑ Client Doesn't Know Client Refused - Client Refused Data ❑ Incomplete or estimated ❑ Client Refused Data not Collected _ Data not Collected Quality: address reported ❑ Data not Collected Phone Number Phone Type Contact Preference - Home ❑ Work - Phone Main: ()- x ❑ Leave message ❑ Cell ❑ Message ❑ Alternate Phone Center ❑ Text ❑ Home ❑ Work ❑ Email Alternate: (_)_- x ❑ Leave message ❑ Cell ❑ Message Center Email @ Notes Housing Status: ' Family Type: ❑ Category 1 - Homeless ❑ Client Doesn't Know - Unaccompanied ❑ Category 2 —At Imminent Risk of Losing Housing (within 14 days or less) ❑ Client Refused ❑ Single Parent ❑ Category 3 — Homeless only under other Federal Statutes ❑ Data not Collected ❑ Two Parents ❑ Category 4 — Fleeing Domestic Violence ❑ Adults No children ❑ At Risk of Homelessness ❑ Stably Housed Revised 3/2/2016 HMIS Intake and Enrollment Form - General Client Name/ID: Relation to Head of Household) Gwider: E Self [I Male L1 Client Doesn't Know D Head of Household's Child Li Female Li Client Refused Li Head of Household's Spouse or Partner Ll Transgender Female to Male E Data not Collected Li Head of Household's other Relation Member [I Transgender Male to Female Li Other: Non -relation Member E Other (Specify: Disabled? Veteran Education Level (Physical, Developmental, Mental Health, (Have you ever served in (What is the highest level of education you've completed?) Chronic Health Condition, HIVIAIDS, the U.S, Military?) and/or Substance Use Disorder. Ei Yes ❑ Yes Li No Schooling Completed El 12th Grade, no diploma ii No [i No 11 Nursery School to 41h Grade Li High School Diploma L Client Doesn't Know Ei Client Doesn't Know [I 51h or 61h Grade [I GED E Client Refused Ei Client Refused [I 7th or 81h Grade 0 Post -Secondary School Data not Collected Li Data not Collected Li 911 Grade El 4-year College Degree 0 loth Grade Li Graduate School 0 11 1h Grade El Unknown Pay interval Income Source Stated Everyeek Other Twice A (Check all that apply) Income Weekly Quarterly Yearly W Month D No financial resources 77777,,,12?, V MOM 3 U, z x !Monthly El Earned Income (employment wages /cash) $ 11 Ll El 0 El El El Unemployment Insurance $ 11 Ll El 0 11 11 0 El Supplemental Security Income (SSI) $ 1-1 Ll 11 11 El 0 [I Social Security Disability Income (SSDI) $ El El 0 11 11 F1 [I VA Service -Connected Disability Compensation $ El El El Ll 11 El [I VA Non -Service -Connected Disability Pension $ E El 11 El El Ll Li Private Disability Insurance $ El 0 El 11 El 11 El Workers Compensation $ El 0 El 11 El Ll Li Temporary Assistance for Needy Families (CalWORKs) $ El Ej 11 El El El El General Assistance (GA) (General Relief (GR)) $ 11 El El 0 El Ll 11 Retirement Income from Social Security $ 71 El El 0 El Ll El Pension or retirement income from a former job $ El 0 L 11 0 0 El Child Support $ El 0 Ll Ll 0 El [I Alimony or other spousal support $ El El 0 11 0 El El Other Source (Specify: Li Client Doesn't Know El Client Refused A El Data not Collected , � Revised 3/2/2016 HMIS Intake and Enrollment Form - General Client Name/ID Income Documentation (Optional): Comments (Optional): ❑ GR Form ❑ CalWORKS Forms ❑ Pension Letter/Stub ❑ Pay Stub ❑ Unemployment Insurance Forms ❑ Unemployment Forms ❑ Utility Allowance ❑ W-2 Forms ❑ Self Declaration ❑ Child Support Forms ❑ SSDI Form ❑ Employer Printout/Letter ❑ Social Security Forms ❑ Workmans Comp ❑ VA Documentation ❑ SSI Forms ❑ Self Emolovment Docs Non -Cash Benefits (Check all that apply): None L Client Doesn't Know ❑ Client Refused ❑ Data not Collected Food Stamps (CalFresh) ❑ CalWorks Child Care ❑ Temporary Rental Assistance Amount: ❑ CalWorks Transportation ❑ Section 8 or Rental Assistance ❑ Medically Needy ❑ WIC ❑ Other CalWorks-Funded Services ❑ Other Amount: Health Insurance (Check all that apply): Li No Health Insurance ❑ Client Doesn't Know Client Refused ❑ Data not Collected ❑ MEDICAID ❑ MEDICARE ❑ State Children's Health Ins. ❑ VA Medical Services ❑ Employer Provided Health Ins. ❑ COBRA Health Ins. ❑ Private Health Ins. ❑ MediCal Client Note: Type: ❑ Information ❑ Alert Private Customer: ❑ Yes ❑ No Note Date: ! I Contact Type Phone Number Phone Type Email Alternate Contact ❑ Home (Who is the best person to get in ❑ Cell touch with you?) Li Work Relationship: _ X (—)— ❑ Message Center First Name: Last Name: Emergency ❑ Home (!n case of an emergency, who ❑ Cell should we alert?) ❑ Work ❑ Same as above (_)_- X ❑ Message Center Relationship: First Name: Last Name: Revised 3/2/2016 3 HMIS Intake • Enrollment Form Program Entry (All fields required unless otherwise noted) Program Name: Case Manager: Program Entry Date: ! 1. Where did you sleep last night? Emergency shelter Rental by client, with GPD TIP subsidy - Foster care home or foster care group home Rental by client, with other (non-VASH) ongoing housing subsidy - Hospital or other residential non -psychiatric medical facility* r_ Residential project or halfway house with no homeless criteria - Hotel or motel paid for without emergency shelter voucher - Safe Haven - Jail, prison or juvenile detention facility* - Staying or living in a family member's room, apartment, or house - Long-term care facility or nursing home - Staying or living in a friend's room, apartment or house - Owned by client, no ongoing housing subsidy Substance abuse treatment facility or detox center* - Owned by client, with ongoing housing subsidy ^ Transitional housing for homeless persons - Permanent housing for formerly homeless persons ❑ Other Place not meant for habitation Client Doesn't Know Psychiatric hospital or other psychiatric facility* Client Refused - Rental by client, no ongoing housing subsidy Data not Collected Rental by client, with VASH housing subsidy 1a. If "Other" prior residence was selected, pleasespecify (Required only if question #1 was answered as "Other") 2. How long was your stay? One day or less* a One to three months* ❑ Client Doesn't Know ❑ Two days to one week* ❑ More than three months, but less than one year ❑ Client Refused n More than one week, but less than one month* ❑ One year or longer ❑ Data not Collected 3. Client entering from the streets, ES, or SH? ❑ Yes ❑ Client Doesn't Know ❑ Data not Collected No ❑ Client Refused 3a. Approximate date started (Required only if the previous question was answered 'Yes' 4. Number of times the client has been on the streets, in ES, or SH in the past three years including today. Never in three years ❑ Three times Client Doesn't Know ❑ One time -_ Four or more times ❑ Client Refused ❑ Two times ❑ Data not Collected 4a. Total number of months homeless on the streets, in ES, or SH in the past three years (Required only if question #4 was answered as '1, 2, 3, or 4 or more times' Ei One month (this time is the first month) C 7 ❑ 12 112 ❑ 8 ❑ More than 12 months ❑ 3 ❑ 9 ❑ Client Doesn't Know ❑ 4 ❑ 10 ❑ Client Refused ❑ 5 ❑ 11 ❑ Data not Collected El Revised 3/2/2016 4 HMIS Intake and Enrollment Form - General Client Name/ID: Question Check One Answer Comments 5. Where were you sleeping prior to _ Emergency shelter entering the institutional setting mentioned Foster care home or foster care group home above (in question #1)? Hospital or other residential non -psychiatric medical facility Hotel or motel paid for without emergency shelter voucher (Required if question #2 was answered Jail, prison or juvenile detention facility as three months or less (*) AND question - Long-term care facility or nursing home #1 was answered as one of the following Owned by client, no ongoing housing subsidy (*): -i Owned by client, with ongoing housing subsidy -"Hospital or other residential non- �i Permanent housing for formerly homeless persons psychiatric medical facility" ❑ Place not meant for habitation -"Jail, prison or juvenile detention ❑ Psychiatric hospital or other psychiatric facility facility" ❑ Rental by client, no ongoing housing subsidy -"Psychiatric hospital or other 7 Rental by client, with VASH housing subsidy psychiatric facility" Rental by client, with GPD TIP subsidy -"Substance abuse treatment facility - Rental by client, with other (non-VASH) ongoing housing or detox center" subsidy _ Residential project or halfway house with no homeless criteria Safe Haven Staying or living in a family member's room, apartment, or house - Staying or living in a friend's room, apartment or house Substance abuse treatment facility or detox center Transitional housing for homeless persons Other Client Doesn't Know Client Refused Data not Collected 6. What city were you residing in Aliso Viejo ❑ Irvine San immediately prior to entry into this project? Anaheim ❑ La Habra Clemente Atwood La Palma San Juan Balboa Laguna Beach Capistrano Brea Laguna Hills Santa Ana Buena Park Laguna Niguel Seal Beach Capistrano Beach Laguna Woods _ Stanton Corona del Mar Lake Forest Sunset Costa Mesa Las Flores Beach Coto de Caza Lemon Heights Tustin Cypress Los Alamitos Villa Park Dana Point Midway City Westminster ElModena Mission Viejo Yorba Linda Fountain Valley Newport Beach Outside Fullerton Orange Orange County Garden Grove Placentia Client Huntington Beach Rancho Santa Doesn't Know Margarita _ Client Refused Data not Collected 7. Was the client referred to this project Yes through Coordinated Entry? No (Required for PSH projects only) Revised 3/2/2016 HMIS Intake and Enrollment Form - General Client Name/ID: Question Check One Answer Comments 8. Have you been diagnosed with AIDS or have you tested positive ❑ No - Client Doesn't Know for HIV? ❑ Yes** ❑ Client Refused ❑ Data not Collected 8a. Do you expect this to substantially impair your ability to live El N0 ElClient Doesn't Know independently? 11 Client Refused (Required if question 8 is 'Yes') El Yes ❑ Data not Collected 8b. Do you have documentation of the disability and severity on file? ❑ No ❑ Yes (Required if question 8 is 'Yes') 8c. Are you currently receiving services/treatment for this El Client Doesn't Know El N0 disability? ❑ Client Refused (Required if question 8 is 'Yes') El Yes ❑ Data not Collected 9. Do you have a chronic health condition? ❑ Client Doesn't Know ❑ No - Client Refused ❑ Yes** Data not Collected 9a. Do you expect this to be of long -continued and indefinite ❑ No ❑ Client Doesn't Know duration AND substantially impair your ability to live ❑ Yes ❑ Client Refused independently? (Required if question 9 is 'Yes')El Data not Collected 9b. Do you have documentation of the disability and severity on file? ❑ No ❑ Yes (Required if question 9 is 'Yes' 9c. Are you currently receiving services/treatment for this ❑ No ❑ Client Doesn't Know disability? ❑ Yes ❑ Client Refused (Required if question 9 is `Yes') ❑ Data not Collected 10. Do you have a physical disability? ❑ Client Doesn't Know ❑ No ❑ Client Refused ❑ Yes** ❑ Data not Collected 10a. Do you expect this to be of long —continued and indefinite ❑ Client Doesn't Know duration AND substantially impair your ability to live ❑ No ❑ Client Refused independently? ❑ Yes (Required if question 10 is'Yes' [I Data not Collected 10b. Do you have documentation of the disability and severity on file? ❑ No ❑ Yes (Required if question 10 is 'Yes') 10c. Are you currently receiving services/treatment for this El Client Doesn't Know disability? El N0 El Client Refused (Required if question 10 is 'Yes') El ❑ Data not Collected 11. Do you currently have a drug or alcohol problem? ❑ No ❑ Client Doesn't Know ❑ Alcohol** ❑ Client Refused ❑ Drug** ❑ Data not Collected ❑ Both** 11 a. Do you expect this to be of long —continued and indefinite ❑ Client Doesn't Know duration AND substantially impair your ability to live ❑ No ❑ Client Refused independently? ❑ Yes ❑ Data not Collected (Required if question 11 is'Alcohol','Dru ', or'Both' 11 b. Do you have documentation of the disability and severity on file? ❑ No ❑ Yes (Required if question 11 is'Alcohol','Dru ', or'Both' Revised 3/2/2016 HMIS Intake and Enrollment Form - General Client Name/ ID: 11c. Are you currently receiving services/treatment for this ❑ Client Doesn't Know disability? El N0 El Client Refused (Required if question 11 is `Alcohol', `Drug', or `Both') El ❑ Data not Collected 12. Have you ever been told you have a learning disability or ❑ Client Doesn't Know developmental disability? ❑ N0 ❑ Client Refused ❑ Yes* ❑ Data not Collected 12a. Do you expect this to be of long —continued and indefinite ❑ Client Doesn't Know duration AND substantially impair your ability to live ❑ No ❑ Client Refused independently? ❑ Yes not Collected (Required if question 12 is 'Yes')❑Data 12b. Do you have documentation of the disability and severity on file? ❑ No ❑ Yes (Required if question 12 is `Yes' 12c. Are you currently receiving services/treatment for this ❑ Client Doesn't Know disability? El Client Refused (Required if question 12 is 'Yes') ❑ Yes ❑ Data not Collected 13. Do you feel you currently have a mental health problem? ❑ Client Doesn't Know ❑ No ❑ Client Refused ❑ Yes** ❑ Data not Collected 13a. Do you expect this to be of long —continued and indefinite ❑ Client Doesn't Know duration AND substantially impair your ability to live ❑ No ❑ Client Refused independently? ❑ Yes (Required if question 13 is'Yes' ❑Data not Collected 13b. Do you have documentation of the disability and severity on file? ❑ No ❑ Yes (Required if question 13 is `Yes' 13c. Are you currently receiving services/treatment for this ❑ Client Doesn't Know disability? ❑ N0 ❑ Client Refused (Required if question 13 is 'Yes') ❑Yes ❑ Data not Collected 14. Have you been a victim of domestic violence or a victim of ❑ No ❑ Client Doesn't Know intimate partner violence? ❑ Yes ❑ Client Refused [I Data not Collected 14a. How long ago did you have this experience? ❑ Within the past three months (Required if question 14 is 'Yes') ❑ Three to six months ago (excluding six months exactly) ❑ From six to twelve months ago (excluding one year exactly) ❑ More than a year ago ❑ Client Doesn't Know ❑ Client Refused ❑ Data not Collected 14b. Are you currently fleeing? ❑ No ❑ Client Doesn't Know (Required if question 14 is 'Yes' ❑ Yes ❑ Client Refused ❑ Data not Collected Revised 3/2/2016 HMIS Intake and Enrollment Form - General Client Name/ ID: Question Check One Answer Comments 15. Are you currently employed? ❑ No Client Doesn't Know ❑ Yes - Client Refused 15a. Why are you not employed? ❑ Looking for work (Required if question 15 is `No') ❑ Unable to work ❑ Not looking for work 15b. What type of employment do you have? ❑ Full-time (Required if question 15 is `Yes') ❑ Part-time ❑ Seasonal / sporadic(including day labor Question Check One Answer Comments 16. Are you pregnant? ❑ No ❑ Client Doesn't Know ❑ Yes ❑ Client Refused 16a. What is your due date? I I (Required if question 16 is `Yes' Question Check One Answer Comments 17. Did you run away from home or a foster care home? ❑ No ❑ Client Doesn't Know ❑ Yes ❑ Client Refused Question Check One Answer Comments 18. Which branch of the military did you serve in? ❑ Army ❑ Coast Guard Air Force ❑ Client Doesn't Know ❑ Navy ❑ Client Refused ❑ Marines ❑ Data not Collected 19. What type of discharge did you receive? ❑ Honorable ❑ General under honorable conditions ❑ Other than honorable conditions (OTH) ❑ Bad Conduct ❑ Dishonorable ❑ Uncharacterized ❑ Client Doesn't Know ❑ Client Refused ❑ Data not Collected 20. When did you enter military service? / / ❑ Doesn't Know 21. When did you separate from military service? I I - Doesn't Know 22. Household Income as a Percentage of AMI ❑ Less than 30% ❑ 30% to 50% ❑ Greater than 50% Revised 3/2/2016 HMIS Intake and Enrollment Form - General Client Name/ ID: Did you serve in any of the followinq wars/war eras? 23. World War II ❑ No ❑ Client Doesn't Know Dec. 1941— Dec. 1946 ❑ Yes ❑ Client Refused ❑ Data not Collected 24. Korean War ❑ No ❑ Client Doesn't Know Jun. 1950 — Jan. 1955 ❑ Yes ❑ Client Refused ❑ Data not Collected 25. Vietnam War ❑ No ❑ Client Doesn't Know Feb. 1961 — May 1975 ❑ Yes ❑ Client Refused ❑ Data not Collected 26. Persian Gulf War (Operation Desert Storm) ❑ No ❑ Client Doesn't Know Aug. 1990 — April 1991 ❑ Yes ❑ Client Refused ❑ Data not Collected 27. Afghanistan (Operation Enduring Freedom) ❑ No ❑ Client Doesn't Know Oct. 2001 - Present ❑ Yes ❑ Client Refused ❑ Data not Collected 28. Iraq (Operation Iraqi Freedom) ❑ No ❑ Client Doesn't Know Mar. 2003 —Aug. 2010 ❑ Yes ❑ Client Refused ❑ Data not Collected 29. Iraq (Operation New Dawn) ❑ No ❑ Client Doesn't Know Sept. 2010 — Dec. 2011 ❑ Yes ❑ Client Refused ❑ Data not Collected 30. Other Peace -keeping Operations or Military ❑ No ❑ Client Doesn't Know Interventions (such as Lebanon, Panama, ❑ Yes ❑ Client Refused Somalia, Bosnia, Kosovo) ❑ Data not Collected Question Check One Answer Comments ASSESSOR ONLY — DO NOT ASK: ❑ No 31. Is the client chronically homeless? ❑ Yes To be chronically homeless, the client must be a homeless individual or a family with an adult head of household (or if there is no adult in the family, a minor head of household) with a disability who lives in a place not meant for human habitation, a safe haven, or in an emergency shelter; and has been homeless continuously for at least 12 months or on at least 4 separate occasions in the last 3 years where the combined occasions equal at least 12 months Question Check One Answer Comments 32. In Permanent Housing? - No Yes 32a. If yes to previous question, date of move -in: (Required if question 32 is `Yes' 1 1 I certify that the information above is correct to the best of my knowledge. Client Signature Site Date Revised 3/2/2016 HMIS Intake and Enrollment Form - General Client Name/ ID: Agency Staff Signature Site Date DO NOT WRITE IN BOX BELOW — DATA ENTRY PERSONNEL ONLY (Optional): Date entered into HMIS Question Answer Initials of Staff Comments completion Was the hard copy exit form completely _ Yes filled out correctly? No Staff Name (verifying completion of Data Entry): Revised 3/2/2016 10 Mercy House Exhibit A — Appendix A2 HMIS Consent Form GREATER Los ANGELES & ORANGE COUNTY HOMELESS MANAGEMENT INFORMATION SYSTEM (LA%OC HMIS) CONSENT TO SHARE PROTECTED PERSONAL INFORMATION The LA/OC HMIS is a local electronic database that securely record information (data) about clients accessing housing and homeless services within the Greater Los Angeles and Orange Counties. This organization participates in the HMIS database and shares information with other organizations that use this database. This information is utilized to provide supportive services to you and your household members. What information is shared in the HMIS database? We share both Protected Personal Information (PPI) and general information obtained during your intake and assessment, which may include but is not limited to: • Your name and your contact information • Your social security number • Your birthdate • Your basic demographic information such as gender and race/ethnicity • Your history of homelessness and housing (including your current housing status, and where and when you have accessed services) • Your self -reported medical history, including any mental health and substance abuse issues • Your case notes and services • Your case manager's contact information • Your income sources and amounts; and non -cash benefits • Your veteran status • Your disability status • Your household composition • Your emergency contact information • Any history of domestic violence • Your photo (optional) How do you benefit from providing your information? The information you provide for the HMIS database helps us coordinate the most effective services for you and your household members. By sharing your information, you may be able to avoid being screened more than once, get faster services, and minimize how many times you tell your `story.' Collecting this information also gives us a better understanding of homelessness and the effectiveness of services in your local area. Who can have access to your information? Organizations that participate in the HMIS database can have access to your data. These organizations may include homeless service providers, housing groups, healthcare providers, and other appropriate service providers. Version 1.1 Page 1 of 3 Modified 912312015 How is your personal information protected? Your information is protected by the federal HMIS Privacy Standards and is secured by passwords and encryption technology. In addition, each participating organization has signed an agreement to maintain the security and confidentiality of the information. In some instances, when the participating organization is a health care organization, your information may be protected by the privacy standards of the Health Insurance Portability and Accountability Act (HIPAA). By signing below, you understand and agree that: • You have the right to receive services, even if you do not sign this consent form. • You have the right to receive a copy of this consent form. • Your consent permits any participating organization to add to or update your information in HMIS, without asking you to sign another consent form. • This consent is valid for seven (7) years from the date the PPI was created or last changed. • You may revoke your consent at any time, but your revocation must be provided either in writing or by completing the Revocation of Consent form. Upon receipt of your revocation, we will remove your PPI from the shared HMIS database and prevent further PPI from being added. The PPI that you previously authorized to be shared cannot be entirely removed from the HMIS database and will remain accessible to the limited number of organization(s) that provided you with direct services. • The Privacy Notice for the LA/OC HMIS contains more detailed information about how your information may be used and disclosed. A copy of this notice is available upon request. • No later than five (5) business days of your written request, we will provide you with: 0 A correction of inaccurate or incomplete PPI o A copy of your consent form 0 o A copy of your HMIS records; and o A current list of participating organizations that have access to your HMIS data. • Aggregate or statistical data that is released from the HMIS database will not disclose any of your PPI. • You have the right to file a grievance against any organization whether or not you sign this consent. • You are not waiving any rights protected under Federal and/or California law. Version 1.1 Page 2 of 3 Modified 912312015 SIGNATURE AND ACKNOWLEDGEMENT Your signature below indicates that you have read (or been read) this client consent form, have received answers to your questions, and you freely consent to have your information, and that of your minor children (if any), entered into the HMIS database. You also consent to share your information with other participating organizations as described in this consent form. 0 I consent to sharing my photograph. (Check here) Client Name: DOB: Last 4 digits of SS Signature Date 0 Head of Household (Check here) Minor Children (if any): Client Name: DOB: Last 4 digits of SS Living with you? (YJN) Client Name: DOB: Last 4 digits of SS Living with you? (YJN) Client Name: DOB: Last 4 digits of SS Living with you? (YJN) Print Name of Organization Staff Print Name of Organization Signature of Organization Staff Date Version 1.1 Page 3 of 3 Modified 912312015 Mercy House Exhibit A — Appendix A3 Disclosure Consent Form Mercy House P.O. Box 1905 Santa Ana, CA 92702 (714)836-7188 (714)867-7901 - fax Disclosure Consent Form Name: Date of birth: If consent is given, it remains in effect for the duration of residency or until the consent is revoked in writing. You will receive a copy of this form once signed. kxie �exxxkxxx9e 9ekxkkkkkkkk4ex Sex kxxxxxkkkxx kxxx'xkk9ckkkkkkxkxx kxx kxxxxkkxxkkk Individual to check the appropriate boxes: ❑ I authorize the exchange of information between Mercy House and ❑ I authorize to release (name of agency or individual releasing information) (name of agency or individual releasing information) (specify information) ❑ I authorize Mercy House to release to (name of agency or individual receiving information) Signature to Mercy House. (specify information) Date Mercy House Exhibit A — Appendix A4 Release of Information Authorization RELEASE OF INFORMATION AUTHORIZATION: I understand that I am NOT guaranteed this assistance. I understand that at any time it may be necessary for Mercy House to share information or request information from other agencies (public and non-profit) and other sources, but not limited to landlords, service providers, etc. I hereby authorize Mercy House to seek and/or share information relevant to my request for assistance from Mercy House. I further certify under the penalty of perjury that all information I have provided is true and correct, and I have given my permission for verification and understand that the discovery of any false information is grounds for denial or termination of services. Note: This form is signed by the head of household on behalf of all household members. Print Head of Household Name Head of Household Signature Date 'We kelp people findtheirway 6ackhome. P.O. Box 1905 ♦ Santa Ana, CA 92702 ♦ (714) 836-7188 ♦ Fax (714) 836-7901 www.mercyhouse.net Mercy House Exhibit A — Appendix A5 Household Obligation & Responsibilities Household Obligations & Responsibilities Head of Household Name: Date: A. The Household MUST: 1. Supply any information that your Mercy House case manager determines necessary, including but not limited to evidence of citizenship and/or eligible immigration status. 2. Disclose social security numbers, for ALL household members, sign and submit forms needed to verify income information and submit documents as required for use in regularly scheduled reviews of household income. 3. Participate in all case managers requests; attend all appointments and follow-up with all referrals as recommended. Develop with your case manager a service plan to address housing, benefits education and employment goals. 4. Comply with all provisions of the lease. 5. Give a written 30-day notice to property owner and your case manager before you move or terminate from the Mercy House Program (if applicable). 6. The assisted unit must be the family's only residence. 7. Give your case manager copy of any warning, eviction/3 day pay or quit notice. B. The Household (including each household member) MUST NOT: 1. Commit any serious or repeated violation of the lease 2. Commit fraud, bribery, or any other corrupt or criminal act in connection with the program 3. Participate in illegal alcohol, drug, or violent criminal activity. 4. Sublease or let the unit or assign the lease or transfer the unit. 5. Damage the unit or premises (other than damage from the ordinary wear and tear) or permit any quest to damage the unit or premises. 6. Give Cash to any case manager at any time. CERTIFICATION OF THE FAMILY: I have read and received a copy of this Statement of Household Obligations and Responsibilities. I certify that I am in compliance with all of the Obligations and Responsibilities of the Household, and I acknowledge that my rental assistance may be terminated if I violate one or more of the rules listed above. Note: this form is signed by the head of household on behalf of all household members. Head of household Signature: We help people find their way hackhome. Date: P.O. Box 1905 v Santa Ana, CA 92702 v (714) 836-7188 v Fax (714) 836-7901 www.mercyhouse.net Mercy House Exhibit A — Appendix A6 Declaration of Alternate Housing Attempts DECLARATION OF ALTERNATE HOUSING ATTEMPTS: Head of House Hold Name: ❑ I certify, under penalty of perjury, that following information is true and complete: I, (Head of House hold) declare that I would be homeless or will continue to be homeless without this assistance, as no subsequent residence has been identified and I lack the resources and support networks needed to obtain housing. See below a list of the efforts made to obtain a subsequent residence: List efforts & why it is not an option: 1. 2. 3. Head of House hold Signature: Date: Note: this form is signed by the head of household on behalf of -all household members. Mercy House Exhibit A — Appendix B TBRA Application HOME Tenant -Based Rental Assistance (TBRA) Program APPLICANT NAME: CURRENT ADDRESS: CITY, STATE, ZIP CODE: HOME PHONE: EMAIL ADDRESS: APPLICATION ALTERNATE PHONE: HOUSEHOLD COMPOSITION (List the Head of Household and all other members who will be living in the unit. Give the relationship of each family member to the head.) FULL NAME I RELATIONSHIP I BIRTHRATE I AGE I SEX I SOCIAL SECURITY NO.11 HUNTINGTON BEACH RESIDENCY Are you a resident of the city of Huntington Beach: ❑ Yes ❑ No Last permanent address: (Application must include proof of Huntington Beach residency or proof of employment in Huntington Beach) U.S. VETERANS PREFERENCE Are you a U.S. veteran that has been released or discharged under honorable conditions? ❑ Yes ❑ No (Application must include proof of service and honorable discharge paperwork) ELIGIBILITY REQUIREMENTS Eligibility is limited to individuals and families who are currently homeless or residing in a transitional housing facility and meet one of the following conditions (please check the appropriate box and attach documentation verifying status): ❑ Documentation from a Huntington Beach school that the children in the household have been enrolled in and attending the school for at least the last 90 days from the time of admission into the Program. ❑ Documentation from a partner agency, such as the Huntington Beach Police Department, evidencing that the family is known to be homeless in Huntington Beach. ❑ Proof that the applicant's last place of stable residency was in the City of Huntington Beach. Verification from a landlord is acceptable. ❑ Proof that an adult member of the household is working or has been recently hired to work in Huntington Beach. Households must meet at least one of the following criteria or met one of the following criteria prior to entering into a current transitional housing program (Check the appropriate box and attach documentation verifying status): ❑ Sleeping in an emergency shelter; ❑ Sleeping in a place not meant for human habitation, such as, cars, parks, abandoned buildings, streets/sidewalks; ❑ Staying in a hospital or other institution for up to 180 days but was sleeping in an emergency shelter or other place not meant for human habitation (cars, parks, streets, etc.) immediately prior to entry into the hospital or institution; ❑ Victims of domestic violence; and ❑ Those at -risk of homelessness. HOUSEHOLD INCOME AND BENEFITS What is the total gross monthly income of all household members? (Please include wages, salaries and tips, social security, TANF, child support, alimony, regular monetary contributions from family and/or friends, or other benefits). If additional space is needed, please attach separate sheets. NAME GROSS MONTHLY AMOUNT SOURCE OF INCOME (I.E. WAGES, SSI, SSD, TANF, DISABILITY, ANNUITIES, RETIREMENT, CHILD SUPPORT, ETC). ASSET INFORMATION List the type and source of any family assets. Provide both the current cash value and the estimated annual income from the asset. NAME TYPE AND SOURCE OF ASSET (BANK ACCOUNTS, INVESTMENTS, ETC.) CASH VALUE OF ASSET ANNUAL INCOME FROM ASSET OTHER SECTION 8 WAITING LISTS ARE YOU CURRENTLY ON A WAITING LIST TO RECEIVE SECTION 8 RENTAL ASSISTANCE (I.E. HOUSING AUTHORITY OF THE COUNTY OF SAN BERNARDINO, UPLAND HOUSING AUTHORITY, ETC. ❑ YES ❑ No IF YES, PLEASE LIST WHICH PUBLIC HOUSING AUTHORITY: (NAME) (ADDRESS AND PHONE NUMBER APPLICATION CERTIFICATION: I/we understand that the above information is being collected to determine if I/we are eligible to receive rental assistance. 1/we authorize the Mercy House and the City of Huntington Beach to verify all information provided on this application. HEAD OF HOUSEHOLD SIGNATURE AND DATE SIGNATURE OF ALL OTHER HOUSEHOLD MEMBERS AND DATE SIGNATURE OF ALL OTHER HOUSEHOLD MEMBERS AND DATE SIGNATURE OF ALL OTHER HOUSEHOLD MEMBERS AND DATE SIGNATURE OF ALL OTHER HOUSEHOLD MEMBERS AND DATE SIGNATURE OF ALL OTHER HOUSEHOLD MEMBERS AND DATE Mercy House Exhibit A — Appendix C1 Homeless Declaration DECLARATION OF HOMELESSNESS STATUS (continued) Applicant Name: Staff Certification I understand that third -party verification is the preferred method of certifying homelessness or risk for homelessness for an individual who is applying for assistance. I understand self declaration is only permitted when I have attempted to but cannot obtain third party verification. Describe in detail efforts made for Third Party verification and attach documentation behind this form (email, phone logs, etc...) Staff Signature: Date: Mercy House Exhibit A — Appendix C2 At -Risk Declaration DECLARATION OF AT -RISK OF HOMELESSNESS STATUS Applicant Name: ❑ I certify, under penalty of perjury, that following information is true and complete: Applicant Signature: Date: `T=Third Party / O=Observation / S= Self-certifi cation Attach Third Partv verification documentation and Intake Observation statements behind this form Verification Type T/O/S*/Notes Situation 1 I [and my household] meet the income qualification. (see Computing Part 5 Annual Income form) ❑ I [and my household] do not have the sufficient resources or support network immediately available to prevent me/us from moving to an emergency shelter or another place not designed for or ordinarily used as a regular sleeping accommodation for human beings. S-include supporting documentation when practical Must meet on of the following ❑ I [and my household] have moved because of economic reasons two or more times during the 60 days immediately preceding the application for homelessness prevention assistance -Document moves AND economic reasons. 0-not allowed ❑ I [and my household] am/are living in the home of another because of economic hardship -Document living situation and economic hardship ❑ I [and my household] have been notified in writing that my right to occupy my current housing or living situation will be terminated within 21 days after the date of application for assistance. Only T is allowed ❑ I [and my household] live/lives in a hotel or motel AND the cost of the hotel or motel stay is not paid by charitable organizations or by Federal, State, or local government programs for low-income individuals -Document housing and payment ❑ I [and my household] live/lives in a single -room occupancy or efficiency apartment unit in which there reside more than two persons or live/lives in a larger housing unit in which there reside more than 1.5 persons reside per room, as defined by the U.S. Census Bureau -Document # of rooms and # of individuals ❑ I [and my household] am/are exiting a publicly funded institution, or system of care (such as a health-care facility, a mental health facility, foster care or other youth facility, or correction program or institution); Verification Type T/O/S*/Notes Situation 2 ❑ I am a child or youth who does not qualify as "homeless" under this section, but qualifies as "homeless" under another federal statute. Only T is allowed Verification Type T/O/S*/Notes Situation 3 ❑ I am a child or youth who does not qualify as "homeless" under this section, but qualify as "homeless" under section 725(2) of the McKinney-Vento Homeless Assistance Act (42 U.S.C. 11434a(2)), and my parent(s) or guardian(s) are living with me. Only T is allowed Staff Certification I understand that third -party verification is the preferred method of certifying homelessness or risk for homelessness for an individual who is applying for assistance. I understand self declaration is only permitted when I have attempted to but cannot obtain third party verification. Describe in detail efforts made for Third Party verification and attach documentation behind this form (email, phone logs, etc...) Staff Signature: Date: Mercy House Exhibit A — Appendix D Rental Assistance Agreement HOME TBRA RENTAL ASSISTANCE CONTRACT LANDLORD NAME & ADDRESS UNIT NO. & ADDRESS TENANT NAME Telephone No. This HOME Rental Assistance Contract ("Contract") is entered into between Mercy House Living Centers ("program administrator") and the Landlord identified above. This Contract applies only to the Tenant family and the dwelling unit identified above. 1. TERM OF THE CONTRACT The term of this Contract shall begin on and end no later than The Contract automatically terminates on the last day of the term of the Lease. 2. SECURITY DEPOSIT A. Mercy House Living Centers will pay a security deposit to the Landlord in the amount of $ The Landlord will hold this security deposit during the period the Tenant occupies the dwelling unit under the Lease. The Landlord shall comply with state and local laws regarding interest payments on security deposits. B. After the Tenant has moved from the dwelling unit, the Landlord may, subject to state and local law, use the security deposit, including any interest on the deposit, as reimbursement for rent or any other amounts payable by the Tenant under the Lease. The Landlord will give the Tenant a written list of all items charged against the security deposit and the amount of each item. After deducting the amount used as reimbursement to the Landlord, the Landlord shall promptly refund the full amount of the balance to the Mercy House Living Centers. C. The Landlord shall immediately notify the Mercy House Living Centers when the Tenant has moved from the Contract unit. 3. RENT AND AMOUNTS PAYABLE BY TENANT AND MERCY HOUSE LIVING CENTERS A. Initial Rent. The initial total monthly rent payable to the Landlord for the first twelve months of this Contract is $ B. Rent Adjustments. With no less than 30 days' notice to the Tenant and Mercy House Living Centers, the owner may propose a reasonable adjustment to be effective no earlier than the 13th month of this Contract. The proposed rent may be rejected by either the Tenant or Mercy House Living Centers. The Tenant may reject the proposed rent by providing the Landlord HOME Rental Assistance Contract (Page Two) with 30 days' written notice of intent to vacate. If Mercy House Living Centers rejects the proposed rent, Mercy House Living Centers must give both the Tenant and the Landlord 30 days' notice of intent to terminate the Contract. C. Tenant Share of the Rent. Initially, and until such time as both the Landlord and the Tenant are notified by Mercy House, Living Centers, the Tenant's share of the rent shall be $ D. Mercy House Living Center's Share of the Rent. Initially, and until such time as both the Landlord and Tenant are notified by Mercy House Living Centers, Mercy House Living Center's share of the rent shall be $ . Neither Mercy House Living Centers, the City of Huntington Beach, nor HUD assumes any obligation for the Tenant's rent, or for payment of any claim by the Owner against the Tenant. Mercy House Living Center's obligation is limited to making rental payments on behalf of the Tenant in accordance with this Contract. E. Payment Conditions. The right of the owner to receive payments under this Contract shall be subject to compliance with all of the provisions of the Contract. The Landlord shall be paid under this Contract on or about the first day of the month for which the payment is due. The Landlord agrees that the endorsement on the check shall be conclusive evidence that the Landlord received the full amount due for the month, and shall be a certification that: I. The Contract unit is in decent, safe and sanitary condition, and that the Landlord is providing the services, maintenance and utilities agreed to in the Lease; 2. The Contract unit is leased to and occupied by the Tenant named above in this Contract; 3. The Landlord has not received and will not receive any payments as rent for the Contract unit other than those identified in this Contract; and 4. To the best of the Landlord's knowledge, the unit is used solely as the Tenant's principal place of residence. F. Overpayments. If Mercy House Living Centers determines that the Landlord is not entitled to any payments received, in addition to other remedies, Mercy House Living Centers may deduct the amount of the overpayment from any amounts due the Landlord, including the amounts due under any other Rental Assistance Coupon Contract. 4. HOUSING QUALITY STANDARDS AND LANDLORD -PROVIDED SERVICES A. The Landlord agrees to maintain and operate the Contract unit and related facilities to provide decent, safe and sanitary housing in accordance with 24 CFR Section 882.109, including all of the services, maintenance and utilities agreed to in the Lease. B. Mercy House Living Centers and the City of Huntington Beach shall have the right to inspect the Contract unit and related facilities at least annually, and at such other times as may be necessary to assure that the unit is in decent, safe, and sanitary condition, and that required maintenance, services and utilities are provided. C. If Mercy House Living Centers determines that the Landlord is not meeting these obligations, Mercy House Living Centers shall have the right, even if the Tenant continues in occupancy, to terminate payment of Mercy House Living Center's share of the rent and/or terminate the Contract. 5. TERMINATION OF TENANCY The Landlord may evict the Tenant following applicable state and local laws. The Landlord must give the Tenant at least 30 days' written notice of the termination and notify Mercy House Living Centers in writing when eviction proceedings are begun. This may be done by providing Mercy House Living Centers with a copy of the required notice to the tenant. 2 1 P a g e HOME Rental Assistance Contract (Page Three) 6. FAIR HOUSING REQUIREMENTS A. Nondiscrimination. The Landlord shall not, in the provision of services or in any other manner, discriminate against any person on the grounds of age, race, color, creed, religion, sex, handicap, national origin, or familial status. The obligation of the Landlord to comply with Fair Housing Requirements insures to the benefit of the United States of America, the Department of Housing and Urban Development, and Mercy House Living Centers, any of which shall be entitled to involve any of the remedies available by law to redress any breach or to compel compliance by the Landlord. B. Cooperation in Quality Opportunity Compliance Reviews. The Landlord shall comply with Mercy House Living Centers and with HUD in conducting compliance reviews and complaint investigations pursuant to all applicable civil rights statutes, Executive Orders and all related rules and regulations. 7. MERCY HOUSE LIVING CENTERS, THE CITY OF HUNTINGTON BEACH, AND HUD ACCESS TO LANDLORD RECORDS A. The Landlord shall provide any information pertinent to this Contract which Mercy House Living Centers, the City of Huntington Beach, or HUD may reasonably require. B. The Landlord shall permit Mercy House Living Centers, the City of Huntington Beach, HUD, or any of their authorized representatives, to have access to the premises and, for the purposes of audit and examination, to have access to any books, documents, papers, and records of the Landlord to the extent necessary to determine compliance with this Contract. 8. RIGHTS OF MERCY HOUSE LIVING CENTERS IF LANDLORD BREACHES THE CONTRACT A. Any of the following shall constitute a breach of the Contract: (1) If the Landlord has violated any obligation under this Contract; or (2) If the Landlord has demonstrated any intention to violate any obligation under this Contract; or (3) If the Landlord has committed any fraud or made any false statement in connection with the Contract, or has committed fraud or made any false statement in connection with any Federal housing assistance program. B. Mercy House's right and remedies under the Contract include recovery of overpayments, termination or reduction of payments, and termination of the Contract. If Mercy House Living Centers determines that a breach has occurred, Mercy House Living Centers may exercise any of its rights or remedies under the Contract. Mercy House Living Centers shall notify the Landlord in writing of such determination, including a brief statement of the reasons for the determination. The notice by Mercy House Living Centers to the landlord may require the Landlord to take corrective action by a time prescribed in the notice. C. Any remedies employed by Mercy House Living Centers in accordance with this Contract shall be effective as provided in a written notice by the Mercy House Living Centers to the Landlord. Mercy House Living Center's exercise or non -exercise of any remedy shall not constitute a waiver of the right to exercise that or any other right or remedy at any time. 3 1 P a g e HOME Rental Assistance Contract (Page Four) 9. MERCY HOUSE LIVING CENTERS RELATION TO THIRD PARTIES A. Mercy House Living Centers does not assume any responsibility for, or liability to, any person injured as a result of the Landlord's action or failure'to act in connection with the implementation of this Contract, or as a result of any other action or failure to act by the Landlord. B. The Landlord is not the agent of Mercy House Living Centers and this Contract does not create or affect any relationship between Mercy House Living Centers and any lender to the Landlord, or any suppliers, employees, contractors or subcontractors used by the Landlord in connection with this Contract. C. Nothing in this Contract shall be construed as creating any right of the Tenant or a third party (other than HUD or the City of Huntington Beach) to enforce any provision of this Contract or to asses any claim against HUD, the City of Huntington Beach, Mercy House Living Centers, or the Landlord under this Contract. 10. CONFLICT OF INTEREST PROVISIONS A. No employee of Mercy House Living Centers who formulates policy or influences decisions with respect to the Tenant -Based Rental Assistance Program, and no public official or member of a governing body or state of local legislator who exercise his functions or responsibilities with respect to the program shall have any direct or indirect interest during this person's tenure, or for one year thereafter, in this contract or in any proceeds or benefits arising from the Contract or to any benefits which may arise from it. It. TRANSFER OF THE CONTRACT The Landlord shall not transfer in any form this Contract without the prior written consent of Mercy House Living Centers. Mercy House Living Centers shall give its consent to a transfer if the transferee agrees in writing (in a form acceptable to Mercy House Living Centers) to comply with all terms and conditions of this Contract. 12. ENTIRE AGREEMENT: INTERPRETATION A. This Contract contains the entire agreement between the Landlord and Mercy House Living Centers. No changes in this Contract shall be made except in writing signed by both the Landlord and Mercy House Living Centers. B. The Contract shall be interpreted and implemented in accordance with HUD requirements. 41Paoe HOME Rental Assistance Contract (Page Five) 13. WARRANTY OF LEGAL CAPACITY AND CONDITION OF UNIT A. The Landlord warrants the unit is in decent, safe, and. sanitary condition as defined in 24 CFR Section 882.109, and that the Landlord has the legal right to lease the dwelling unit covered by this Contract during the Contract term. B. The party, if any, executing this Contract on behalf of the Landlord hereby warrants that authorization has been given by the Landlord to execute it on behalf of the Landlord. Landlord Name (Type or Print): Mercy House Living Centers Representative (Type of Print): (Signature/Date) (Signature/Date) WARNING: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willingly makes or uses a document or writing containing any false, fictitious, or fraudulent statements or entries, in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000, or imprisoned for not more than five years, or both. LANDLORD'S CHECK TO BE MAILED TO: SS NO. NAME(S ADDRESS SIGNATURE OF OWNER DATE SIGNATURE OF OWNER DATE 51Page Mercy House Exhibit A —Appendix E Landlord Sub Agreement Date: To: (Landlord, Property Manager or Owner) On Behalf of: (Client name) Address: (Client name) has been approved for assistance through the Emergency Solutions Grant (ESG). This program may provide funding for housing relocation and stabilization services and/or short -/medium -term rental assistance to those at risk of becoming homeless or to rapidly re -house those who have become homeless. As part of the assistance, Mercy House will make financial assistance payments to (Landlord, Property Manager or Owner), on behalf of (Client name), using a corporate check. The payment will be mailed or hand delivered by Mercy House staff to the address noted at the bottom. If at any time during the term of this agreement a notice is given to the program participant to vacate the housing unit, or any complaint used under state or local law to commence an eviction action against (Client name), (Landlord, Property Manager or Owner) shall also provide copy of said notice to Mercy House at the address noted at the bottom. Mercy House will make timely payments to (Landlord, Property Manager or Owner) in accordance with the tenant rental agreement information below: Payment Due Date: of the month Grace Period: _of the month Late Payment Requirements: $ ESG assistance will be provided in the following amounts: Tenant will be responsible for the following amounts: Security Deposit Rental for month Rental for month Rental for month Security Deposit Rental for month of Rental for month of Rental for month of The amounts above may represent the entire or partial amount of rent for each month and (Client name) shall be responsible for any balance due. In addition, any late fees or penalties incurred are the sole responsibility of (Client name). If the renter is unable to provide the balance due amount for a particular month, the payment provided by Mercy House for that month shall be returned directly to Mercy House. If the sponsoring agency has paid a security deposit for the renter, these funds shall NOT be returned to Mercy House. If: the program participant moves out of the housing unit; the lease terminates and is not renewed; or the program participant becomes ineligible to receive ESG rental assistance then: the rental assistance agreement with the owner must terminate and no further rental assistance payments may be made under that agreement Both, the Mercy House and (Landlord, Property Manager or Owner) agree to the terms noted above. Please sign below Agency Representative Signature Print name Date Mercy House P.O. BOX #1905 Santa Ana, CA 92702 Phone: (714)836-7188 ext: Fax:(714)667-7912 Email: Landlord, Property Manager or Owner Signature Print name Date Address check to: Address Line 1: Address Line 2: Phone: Fax: Email: We kelp people find their way 6ackhorne P.O. Box 1905 v Santa Ana, CA 92702 v (714) 836-7188 v Fax (714) 667-7912 www.mercyhouse.net Mercy House Exhibit A — Appendix F HOME Program Lease Addendum HOME LEASE ADDENDUM TENANT LANDLORD UNIT NO. & ADDRESS This lease addendum adds the following paragraphs to the Lease between the Tenant and Landlord referred to above. A. Purpose of the Addendum. The lease for the above -referenced unit is being amended to include the provisions of this addendum because the Tenant has been approved to receive rental assistance under the Huntington Beach HOME Rental Assistance Program. Under the Rental Assistance Program, Mercy House Living Centers will make monthly payments to the Landlord on behalf of the Tenant. The Lease has been signed by the parties on the condition that Mercy House Living Centers and Landlord will promptly execute a HOME Rental Assistance Contract. This Lease shall not become effective unless the Contract has been executed by both the Landlord and Mercy House Living Centers, effective the first day of the term of the Lease. B. Conflict with Other Provisions of the Lease. In case of any conflict between the provisions of this Addendum and other sections of the Lease, the provisions of this Addendum shall prevail. C. Terms of the Lease. The term shall begin on and shall continue until: (1) the Lease is terminated by the Landlord in accordance with applicable state and local Tenant/Landlord laws; (2) the Lease is terminated by the Tenant in accordance with the Lease or by mutual agreement during the term of the Lease; or (3) termination of the HOME Rental Assistance Program Contract by Mercy House Living Centers. D. Rental Assistance Payment. Each month Mercy House Living Centers will make a rental assistance payment to the Landlord on behalf of the Tenant. This payment shall be credited by the Landlord toward the monthly rent payable by the Tenant. The balance of the monthly rent shall be paid by the Tenant. E. Security Deposit (1) The (Tenant/Mercy House Living Centers) has deposited $ with the Landlord as a Security Deposit. The Landlord will hold this security deposit during the period the Tenant occupies the dwelling unit under the Lease. The Landlord shall comply with state and local laws regarding interest payments on security deposits. (2) After the Tenant has moved from the dwelling unit, the Landlord may, subject to state and local laws, use the security deposit, including any interest on the deposit, as reimbursement for rent or any other amounts payable by the tenant under the Lease. The Landlord will give the Tenant a written list of all items charged against the security deposit and the amount of each item. After deducting the amount used as reimbursement to the Landlord, the Landlord shall promptly refund the full amount of the balance to the (Tenant/Mercy House Living Centers). F. Utilities and Appliances. The utilities and appliances listed in Column 1 are provided by the Landlord and included in the rent. The utilities and appliances listed in Column 2 below are not included in the rent and are paid separately by the Tenant. UTILITY/APPLIANCE Included in Rent Tenant Paid Garbage Collection Water/Sewer Heating Fuel (specify) Lights, electric Cooking Fuel (specify) Other (specify) Refrigerator Stove/Range G. Household Members. Household members authorized to live in this unit are listed below. The Tenant may not permit other persons to join the Household without notifying Mercy House Living Centers and obtaining the Landlord's permission. Household members: H. Housing Quality Standards. The Landlord shall maintain the dwelling unit, common areas, equipment, facilities and appliances in decent, safe, and sanitary condition (as determined by Section 8 Housing Quality Standards). I. Termination of Tenancy. The Landlord may evict the Tenant following applicable state and local laws. The landlord must provide the Tenant with at least 30 days' written notice of the termination. The Landlord must notify Mercy House Living Centers in writing when eviction proceedings are begun. This may be done by providing Mercy House Living Centers with a copy of the required notice to the Tenant. J. Prohibited Lease Provision. Any provision of the Lease which falls within the classifications below shall not apply and not be enforced by the Landlord. (1) Confession of Judgment. Consent by the Tenant to be sued, to admit guilt, or to a judgment in favor of the landlord in a lawsuit brought in connection with the Lease. (2) Treatment of Property. Agreement by the Tenant that the Landlord may take or hold the Tenant's property, or may sell such property without notice to the Tenant and a court decision on the rights of the parties. (3) Excusing the Landlord from Responsibility. Agreement by the Tenant not to hold the Landlord or Landlord's agent legally responsible for any action or failure to act, whether intentional or negligent. (4) Waiver of Legal Notice. Agreement by the Tenant that the Landlord may institute a lawsuit without notice to the Tenant. (5) Waiver of Court Proceedings for Eviction. Agreement by the Tenant that the Landlord may evict the Tenant Family (i) without instituting a civil court proceedings in which the Family has the opportunity to present a defense, or (ii) before a decision by the court on the rights of the parties. (6) Waiver of Jury Trial. Authorization to the Landlord to waive the Tenant's right to a trial by jury. (7) Waiver of Right to Appeal Court Decision. Authorization to the Landlord to waive the Tenant's right to appeal a court decision or waive the Tenant's right to sue to prevent a judgment from being put into effect. (8) Tenant Chargeable with Cost of Legal Actions Regardless of Outcome of the Lawsuit. Agreement by the Tenant to pay lawyer's fees or other legal costs whenever the Landlord decides to sue, whether or not the Tenant wins. K. Nondiscrimination. The Landlord shall not discriminate against the Tenant in the provision of services, or in any other manner, on the grounds of age, race, color, creed, religion, sex, handicap, national origin, or familial status. TENANT SIGNATURES LANDLORD SIGNATURES By: (Type or Print Name of Tenant Representative) LANDLORD NAME: (Signature/Date) By: (Type or Print Name of Landlord Representative) By: (Type or Print Name of Tenant Representative) (Signature/Date) (Signature/Date) Mercy House Exhibit A — Appendix G Rent Reasonableness and Fair Market Rent Certification RENT REASONABLENESS AND FAIR MARKET RENT CERTIFICATION Proposed Unit Unit #1 Unit #2 Address Number of Bedrooms Square Feet Type of Unit/Construction Housing Condition/Quality Location/Accessibility Amenities Unit: Site: Neighborhood: Age in Years Utilities (type) Unit Rent Utility Allowance Gross Rent Handicap Accessible? CERTIFICATION: A. Rent Proposed Contract Rent + Utility Allowance= Proposed Gross Rent B Compliance with Rent Reasonableness Rent [] is [] is not reasonable in comparison to rent for other comparable unassisted units. C. Compliance with Fair Market Rents Rent [] does [] does not exceed applicable Fair Market Rent of $ Two comparable units must be identified in order to certify Rent Reasonableness. Find listings for comparable units online (on Craigslist or a similar site). ** Print out the listings and attach them in back pocket of folder as proof. *County agreed to go over Fair Market Rent Rates for 2016 Mobile Single home Room Efficiency i Space Occupancy 1-Bedroom 2-Bedroom " 3-Bedroom 4-Bedroom Lent (SRO) ; HUD OC Standards $953 $839 ! $1,161 $1,324 ; $1,672 $2,327 $2,532 (2016) i oC Central Standards $953 $839 $1,119 $1,370 $1,645 $2,310 $2,509 (select Cities)* (2016) oC Restricted payment Standards (for selected citiesireason able $881 $839 $1,119 3 $1,515 $1,780 $2,460 $2,509 accommodations) * (2016) i * CENTRAL PAYMENT STANDARDS: COSTA MESA, FOUNTAIN VALLEY, HUNTINGTON BEACH AND YORBA LINDA. *RESTRICTED PAYMENT STANDARDS: THE FOLLOWING "HIGH RENT AREAS" OF THE COUNTY TO QUALIFY FOR RESTRICTED PAYMENT STANDARDS: ALISO VIEJO, DANA POINT, IRVINE, LAGUNA BEACH, LAGUNA HILLS, LAGUNA NIGUEL, LAKE FOREST, MISSION VIEJO, NEWPORT BEACH, RANCHO SANTA MARGARITA, SAN JUAN CAPISTRANO, SAN CLEMENTE, TUSTIN, AND UNINCORPORATED AREAS SOUTH OF THE 55 FREEWAY. Name: Signature: Date: Mercy House Exhibit A — Appendix H OCHA Utility Allowance Schedule 0 H A N G L {_ 0 U N 8 Y Community Resources Our <ornmunity. Out romrn�tme,ni. ORANGE COUNTY HOUSING AUTHORITY UTILITY ALLOWANCE SCHEDULE HOUSING CHOICE VOUCHER PROGRAM Effective Date: November 1, 2015 Bedroom: 0 12 3 ; , 4 1 5+ GAS Cooking 2 E 7 7 10 12 17 Heating j 12 [ 15 19 28 34 35 W. Heater 1 7 9 9 15 19 21 ELECTRIC Basic j�13 19 23 40 40 40 Cooking 5 8 9 13 18 20 Heating 11 15 20 26 33 37 W. Heater 15 21 27 36 37 37 OTHER Water 1 16 I 19 23 32 38 43 Trash/Sewer j 23 1 23 23 23 23 23 Refrigerator 1 9 I 9 9 9 9 9 Stove ( 7 i 7 7 7 7 7 Mobile Home 62 i 62 62 62 62 62 ORANGE COUNTY HOUSING AUTHORITY 1770 NORTH BROADWAY, SANTA ANAL CA 92706-2642 • PHONE (714) 480-2700 Mercy House Exhibit A — Appendix Case Management Policies I. Intake Process A. Referrals Mercy House Case Management Policies 1. Referrals accepted from any source — preference will be given to referrals received from Huntington Beach Police Officers or other City Departments. 2. All Mercy House Programs offer services on a B. Waiting List C. Intake nondiscriminatory basis and ensure that all citizens have access to information regarding the services provided through our programs. Mercy House does not discriminate on the basis of race, color, age, gender, disability, religion, national origin or sexual orientation. In the case of disability Mercy House will make every reasonable accommodation to meet the needs of the client. Mercy House does not discriminate based on religious affiliation or preference. Mercy House also prohibits coercive religious activities. 1. Program Manager (PM/CM) manages waiting list 2. Waiting list is closed at 20, or as determined by PM/CM 1. When there is an opening, PM/CM contacts the next individual on the waiting list. 2. PM/CM informs client of necessary documentation required to complete process. 3. PM/CM conducts in -person intake and reviews the TBRA program guidelines 4. PM/CM must be able to verify housing status or homeless status per HUD standards prior to service/entry and connection to the City of Huntington Beach. 5. If an eligible client is a close friend or relative of the Case Manager, that client must be referred to another Case Manager. 6. If accepted, schedule case management appointment. 7. If not accepted or ineligible, inform referral of reason why. Note reason on top of first page of intake packet and dead file packet in binder. Mercy House Case Management Policies 8. PM/CM updates status column of waiting list after contact/ attempted contact with referral is made so other staff are aware of status II. Case Management A. Program Manager Schedule 1. PM/CM to complete schedule and update as needed. Schedule is posted in homes and given to client and includes: a. All cm meetings b. Location of meetings (i.e. office, apt) c. PM/CM work schedule (so residents are aware of staff availability) B. Case Management Meetings 1. Case management is held at least monthly 2. Tasks reviewed regularly include: a. finances b. housing and other goals c. employment or job training issues d. volunteering issues (Disabled only) e. resident/staff issues or concerns f. program status: determine continued eligibility C. Program Extension Policy 1. At least twice a year, staff will complete an intake recertification to ensure clients remain eligible 2. Clients who are ineligible will create a plan with their CM to exit the household from the program 3. Though case management and compliance is not a requirement to enter the program, clients who refuse to participate may not be recertified to continue receiving assistance. 2 Mercy House Case Management Policies D. Exiting a Resident 1. PM/CM should begin discussing exit planning immediately after entrance into program 2. PM/CM continually works with resident to prepare for exit 3. For scheduled exits: a. PM/CM begins formal transition with resident at least one month prior to scheduled exit date 1. give resident Exit packet 2. provide resident referrals for housing and assistance programs 3. assist residents with locating housing and completing necessary paperwork 4. For unscheduled exits: a. PM/CM should issue exits with sensitivity b. PM/CM should bring resident into the office or a private location. PM/CM may ask a co-worker to sit in on an exit. c. PM/CM assists to make transition as smooth as possible for exiting resident and other residents d. PM/CM has discretion as to the length of time to give resident to move 1. exception = in cases where resident poses a threat to others, he/she must move out immediately 5. PM/CM to complete a Program evaluation before exiting. E. Closing Case Files 1. Case files to be closed within 30 days of exit 2. Review all forms for completion (file will be returned if forms are incomplete) 3. Write resident name, entry and exit dates and exit status (successful, unsuccessful or neutral) on folder tab 4. If resident did not complete an exit evaluation, write no evaluation on the outside of folder 5. Submit closed file to you Direct Supervisor. 6. Supervisor audits file and initials 7. File returned to PM/CM to archive file in a secured location 3 Mercy House Case Management Policies III. Documentation A. Case Management Files 1. All documentation maintained and secured in case files — no loose documents 2. Case Management Databases should be updated at least monthly 3. Organize case file as outlined in Case File Review form 4. All case files must be kept in a locked file cabinet 5. Never use white out! If you make an error put a line through it and make the correction. 6. All signatures must be in blue ink and the original form should be in the case file. If client send you a form electronically that requires their signature note that in the case file and secure original at the next case management meeting 7. All case management information must be kept confidential and information should not be disclosed to anyone outside the Mercy House staff without a signed disclosure form 8. All client's personal information should be protected and only shared even among Mercy House staff when necessary to ensure the client receives quality assistance 9. All meetings need to be documented in case notes and include: a. date of meeting b. overview of meeting content c. observations/concerns d. staff initials 10. All Supportive Services provided for Client should be clearly documented in Case File. If gift cards, bus passes, or other vouchers are issued they must be listed on Service Sheet in file with client's signature verifying that they received the assistance. A copy of the voucher/card should also be placed in case file. All cards and vouchers issued should also be logged and recorded in accordance with our Gift Card Policy. In the case of FRP or RR if it is necessary for cards to be distributed off site a second staff signature if required. E Mercy House Case Management Policies 11. Case Management meetings should be face to face. If you are unable to meet with the client and connect with them over the phone please note the reason in the case file 12. Case notes should clearly connect to the clients stated housing and other goals IV. Audits A. Case File Reviews 1. Purpose = promote consistency between programs, ensure documents are implemented, prepare for external audits 2. Reviews conducted on a monthly basis or as needed by PD 3. Case files are selected by Supervisor each month for review 4. Once reviewed, staff will receive completed case file review form noting follow-up needed. PM/CM is responsible for correcting and returning completed file review form to Supervisor by date stated on review. B. Voucher / Gift Card Review 1. Program Director will review all Voucher/Gift Card Logs to ensure the amount of cards purchased / distributed match the documentation on a monthly basis. 2. Periodic spot checks will be made to compare the log to individual case files. V. Tracking and Aftercare Programs A. Tracking Program 1. All residents eligible for tracking program 2. Residents must consent to tracking on Exit Interview 3. If consent is obtained, Aftercare Specialist will report progress to PM/CM's at 6 months and 1 year after exit to obtain info on Program Evaluation 4. Aftercare Specialist monitors tracking program and informs PM/CM when contact needs to be initiated 5. Info obtained will be submitted in database. Info will be used to determine long-term success/failure rates. E Mercy House Case Management Policies VI. Reports A. Resident HMIS Database 1. Report provides program and statistical info on residents 2. Report to be updated monthly by PM/CM with updated information on all residents VII. Resources (List of Resources can be accessed on Server) A. Resident/Staff Resources 1. Mercy House Center — emergency services 2. Public Law Center — legal services 3. Legal Aid Society — legal services 4. Mariposa Counseling Center 5. Trinity Counseling Center 6. Rainbow Directory 7. Staff Resource Directory 8. Resident Resource Directory 9. Housing Directory VIII. Internal Meetings A. Program Team Meetings 1. 2°d Monday of each month attended by program staff 2. Staff present cases and receive feedback and support 3. Staff gives update on their program B. Staff Meetings 1. General Meetings quarterly 2. Trainings scheduled as needed IX. Miscellaneous Policies A. Emergency Procedures (see attached Emergency Response Plans for each site) In the case of a Medical Emergency: 0 Mercy House Case Management Policies 1. Observe the situation if the individual is in need of medical assistance and cannot or should not transport him or herself to the doctor's office call 911. 2. Copy the medical information sheet in the resident's case file and have it ready for the paramedics. 3. Write up an incident report and submit it to the ED. 4. Log incident in the Daily log and case file. B. Child Abuse Reporting Procedures 1. Policy a. staff informed of mandated reporter status and what qualifies as abuse upon hire b. residents informed of mandatory reporting under the heading of Childcare in our Resident Handbook 2. Who Reports? a. when an incident is suspected/observed by staff or volunteers the PM/CM will report the incident or the PM/CM will direct the appropriate staff member to report b. when an incident is suspected/observed by a licensed or pre -licensed therapist or social worker he/she is responsible to report the incident 3. If Abuse/Neglect is suspected a. call CPS to see if incident is reportable — (714)940-1000 b. if CPS deems the incident reportable, complete a written report (forms on file at Shelter) c. complete report except for name/title and signature in box B d. remove our copy from report (yellow copy) and file in the Child Abuse Reports binder e. complete name/title and sign report f. submit report within 36 hours 4. Maintaining Written Reports a. written reports will be kept in a binder labeled Child Abuse Reports b. the Child Abuse Reports binder will be kept in a secure location in the office 7 Mercy House Case Management Policies c. reports will be filed in the case file once the resident exits Mercy House 5. Reporting Child Abuse Reports to Staff a. when a report is made the PM/CM will report at the Case Management Meeting following the report that "a child abuse report was filed against...". It is not necessary to disclose who filed the report. b. information surrounding the report will be shared with staff c. information will also be shared at staff meetings at the PM/CM's discretion Mercy House Exhibit B Documentation, Recordkeeping, Reporting and Monitoring Requirements Documentation, Recordkeeping, Reporting and Monitoring Requirements Mercy House (Subrecipient) shall comply with the requirements set forth in this document at all times during the term of the HOME Subrecipient Agreement (Agreement) between the City of Huntington Beach (City) and Subrecipient, to which this document is attached. Documentation and Recordkeeping A. Records to be Maintained Subrecipient shall maintain all records required by the federal regulations specified in 24 CFR 92.508(a)(3), which are pertinent to the Services to be funded under the Agreement. Records shall be maintained for each prospective participant, each Eligible Household and each Housing Unit inspected and/or occupied by an Eligible Household pursuant to the Agreement. Such records shall include but are not limited to: ■ Records providing a full description of each activity undertaken. ■ Records required to determine the eligibility of activities for use of HOME funds. ■ Records (including property inspection reports) demonstrating that each Housing Unit occupied by an Eligible Household meets the property standards of 24 CFR 92.251(d) and 24 CFR 982.401 upon occupancy and at the time of each annual inspection. ■ Records demonstrating compliance with the property standards and financial reviews and actions pursuant to 24 CFR §92.504(d). ■ Records demonstrating that each Eligible Household is income eligible in accordance with 24 CFR 92.203, including all TBRA applications, eligibility determinations and documentation regarding any appeals of eligibility determinations. ■ Records demonstrating that Subrecipient is in compliance with the City's written tenant selection policies and criteria of 24 CFR 92.209(c), including any targeting provisions of 24 CFR 92.209(h), and calculation of each Subsidy Payment. ■ Records demonstrating that each rental agreement for an Eligible Household receiving Subsidy Payments complies with the tenant and participant protections of 24 CFR 92.253. ■ Records documenting compliance with Subrecipients marketing and outreach obligations under the Agreement, including compliance with the fair housing and equal opportunity components of the HOME program and HUD's Affirmative Fair Housing and Marketing regulations and the City's Affirmative Fair Housing Marketing Plan, when adopted. ■ Records documenting compliance with the lead -based hazards requirements under the Agreement, the HOME Program, and 24 CFR Part 35, subparts A, B, J, K, M and R. ■ Financial records as required by 24 CFR §92.508(a)(5) and 24 CFR §92.222. ■ Records documenting the HOME Matching Contributions made by Subrecipient pursuant to the Agreement and the HOME Program, specifically including 24 CFR 92.218 through 24 CFR 92.222. B. Retention The Subrecipient shall retain all financial records, supporting documents, statistical records, and all other records pertinent to the Agreement for a period of five years after the period of Subsidy Payments terminates. Notwithstanding the above, if there are litigation matters, claims, audits, negotiations or other actions that involve any of the records cited and that have started before the expiration of the five-year period, then all pertinent records must be retained until completion of the actions and resolution of all issues, or the expiration of the five-year period, whichever occurs later. C. Client Data The Subrecipient shall maintain client data demonstrating client eligibility for services provided. Such data shall include, but not be limited to, client name, address, income level or other basis for determining eligibility, and description of service provided. Such information shall be made available to City monitors or their designees for review upon request. D. Disclosure The Subrecipient understands that client information collected under this Agreement is private and the use or disclosure of such information, when not directly connected with the administration of the City's or Subrecipient's responsibilities with respect to Services provided under this Agreement, is prohibited unless written consent is obtained from such person receiving services and, in case of a minor, that of a responsible parent/guardian. E. Close Outs The Subrecipient's obligation to the City shall not end until all close-out requirements are completed. Activities during the close-out period shall include, but are not limited to: making final payments, disposing of program assets (including the return of all unused materials, equipment, unspent cash advances, program income balances, and accounts receivable to the City), and determining the custodianship of records. Notwithstanding the foregoing, the terms of this Agreement shall remain in effect during any period that the Subrecipient has control over HOME funds, including program income. F. Audits and Inspections All Subrecipient records with respect to any matters covered by this Agreement shall be made available to the City, HUD and the Comptroller General of the United States or any of their authorized representatives, at any time during normal business hours, as often as deemed necessary, to audit, examine, and make excerpts or transcripts of all relevant data. Any deficiencies noted in audit reports must be fully cleared by the Subrecipient within 30 days after receipt by the Subrecipient. Failure of the Subrecipient to comply with the above audit requirements will constitute a violation of the Agreement and may result in the withholding of future payments. The Subrecipient hereby agrees to have an annual agency audit conducted in accordance with current City policy concerning Subrecipient audits and OMB Circular A-122. II. Quarterly Progress Reports Subrecipient shall submit quarterly progress reports to the City in a form approved or directed by the City on or before each April 15, July 15, October 15 and January 15, which shall include all of the following information regarding Subrecipient's activities during the prior quarter: ■ The number of TBRA applications received, processed, approved and disapproved. ■ The number of Housing Units inspected, approved and disapproved and a description of any corrective work performed by Landlords to comply with HQS. ■ The number of Eligible Households assisted, including specific information regarding the number of and ages of all household members, income categories, types and amounts of assistance provided to each Eligible Household, and remaining terms of assistance expected to be provided to such households. ■ Description of each Eligible Household's participation in required self-sufficiency program and other optional social and supportive Services provided or otherwise made available to each Eligible Household. ■ Budget reconciliation information, including year-to-date expenditures and remaining balance available for Subsidy Payments in accordance with the Budget and the Agreement. ■ Number of additional Eligible Households Subrecipient expects to qualify and assist within the following three-month period. ■ Updated schedule of performance of the Services under the Agreement, including a schedule for qualifying and assisting additional Eligible Households as permitted by the Budget. ■ Information regarding any complaints receipted from Applicants or Eligible Households and any correspondence received from community members or organizations or other nonprofit organizations regarding the Program or specific activities or individuals involved in the Program. ■ Documentation of the HOME Matching Contributions made by Subrecipient pursuant to the Agreement and the HOME Program, specifically including 24 CFR 92.218 through 24 CFR 92.222. III. Performance Monitoring A. Monthly Reports Subrecipient shall provide progress reports on a Monthly basis during the first quarter of the Term of the Agreement in order for the City to review Subrecipient's activities and progress under the Agreement and to ensure that the Program is progressing smoothly. B. City Oversight and Review City will monitor the performance of the Subrecipient against the goals and performance standards set forth in the Agreement. From time to time, City shall be entitled to audit and review Subrecipient's performance of the Services in accordance with the terms of the Agreement and compliance with the HOME Program. Substandard performance as determined by the City will constitute noncompliance with the Agreement. If action to correct such substandard performance is not taken by the Subrecipient within a reasonable period of time after being notified by the City, termination procedures will be initiated in accordance with Section 8.3 of the Agreement. Mercy House Exhibit C Gross Income Calculation From Income Calculation Worksheet • Semi -Monthly pay cycles are usually 15 days or longer from the 1 st - 15th and the 16th - 30th/31 st • Semi -Monthly salaried wage stubs will often show 86.66 or 86.67 under the "hours" section Bi-Weekly pay cycles are usually 14 days and begin on the same day of the week and end on the same day of the week from pay cycle to pay cycle For migrant workers, monthly gross income is coputed by averaging the total gross income received during the previous 12 months and is NOT recalculated until the next annual certification Select Appropriate Income Pay Cycle for Applicant Household Weekly: (52 pay periods annually) Member Name: $ + $ + $ _ $ / 3 = $ Weekly Average $ X 52 pay periods $ gross annual income Member Name: $ + $ + $ _ $ 3 = $ Weekly Average $ X 52 pay periods $ gross annual income Bi-Weekly: (26 pay periods annually) Member Name: $ + $ + $ _ $ 3 = $ Bi-Weekly Average $ X 26 pay periods $ gross annual income Member Name: $ + $ + $ _ $ 3 = $ Bi-Weekly Average $ X 26 pay periods $ gross annual income Semi -Monthly: (24 pay peroids annually) Member Name: $ + $ + $ _ $ 3 = $ Semi -Monthly Avg. $ X 24 pay periods $ gross annual income Member Name: $ + $ + $ _ $ 3 = $ Semi -Monthly Avg. $ X 24 pay periods $ gross annual income Monthly: (12 pay periods annually) Member Name: $ X 12 pay periods $ gross annual income Member Name: $ X 12 pay periods $ gross annual income Fluctuating: use for seasonal, migrant, agricultural, commissions Member Name: $ gross annual income Member Name: $ gross annual income Total Household Annual Income From All Sources Listed Above: © MDG Associates Inc. - 2012 Mercy House Exhibit D Household Budget Worksheet Mercy House Exhibit E Lead -Based Paint Form Lea' -Based Paint Inspection Foi'ti M! TENANT NAME: OWNER NAME: UNIT ADDRESS: OWNER #-. CITY: OWNER PHONE: TELEPHONE #: 1 . UNIT BUILT PRIOR TO 1978? (If NO, Go to #6) El YES El NO 2. CHILDREN IN UNIT UNDER AGE SIX? (if NO, Go to #6) El YES El NO 2A. CHILDREN UNDERAGE SIX WITH IDENTIFIED EBL? El YES El NO NOTE: If there are no children under the age of six, with identified "Elevated Blood Levels (EBL's)", unit requires neither testing, nor abatement, for lead -based paint. If, however, there are children under the age of six years residing in the unit, you must inspect for defective paint surfaces. If children under the age of six, with identified EBL's are residing in the unit, the unit must also be tested for lead -based paint. (See number 5, below). Interior- All deteriorated painted surfaces less than 2 sq. ft. or less than 10% of the component, only stabilization is required. Clearance testing is not required. Exterior- All deteriorated paint surfaces more than 20 sq. ft. on exterior surfaces must be stabilized in accordance with all safe work practice requirements. I Defective paint surfaces: Inspect all interior and exterior surfaces, walls, stairs, deck, porch, railing, windows, doors and any "chewable" surface. CHIPPING El YES El NO SCALING El YES El NO CRACKING F1 YES F-1 NO PEELING F1 YES F] NO LOOSE F -1 F _] I YES F-1 NO OTHER F YES NO 4. UNIT REQUIRES CORRECTION OF DEFECTIVE PAINT SURFACES: El YES El NO 5. UNIT REFERRED FOR TESTING TO: 6. A. NEW LEASE: LEAD -BASED PAINT HAZARDS PRESENT El YES E] NO B. RENEWAL: F-1 UNIT PASSED ❑ OWNER TO CORRECT ALL DEFECTIVE SURFACES ❑ INCONCLUSIVE" TESTING OF PAINT SURFACES REQUIRED [_1 UNIT FAILED- PHA TO TRANSFER TENANT COMMENTS: Mercy House Staff DATE Subsidy No. Date Inspected Pass F1 Fail El -L-d-8—d P Inspec F.I.A.' 02-2— OTT Mercy House Exhibit F ..- TBRA Program Budget Huntington Beach,California Grant Term: 10/1/2018-6/30/2020 Year 1 Year 2 Total Budget 10/1/2018- 6/30/2019 7/1/2019- 6/30/2020 I. HOME Funds Tenant Based Rental Assistance Subsidy $ 330,400.00 $ 78,400.00 $ 252,000.00 Security Deposits Subsidy $ 56,100.00 $ 16,500.00 $ 39,600.00 Utility Deposits Subsidy $ 3,000.00 $ 500.00 $ 2,500.00 Administrative Costs HQS Inspections $ 6,800.00 $ 2,000.00 $ 4,800.00 Income Eligibility $ 3,000.00 $ 1,500.00 $ 3,600.00 Total Administrative Costs $ 11,900.00 $ 3,500.00 $ 8,400.00 Total HOME Funds $ 401,400.00 $ 98,900.00 $ 302,500.00 II. City Inclusionary Funds & LMIAF $ 92,000.00 $ 30,800.00 $ 61,200.00 III. Total City Contract $ 493,400.00 $ 129,700.00 $ 363,700.00 IV. Other Mercy House Funding Sources $ V. Total TBRA Program Budget $ 493,400.00 $ 129,700.00 $ 363,700.00 Tenant Based Rental Assistance Subsidy Assumptions: Assumes 10 households can receive assistance in Year 1. Assumes 24 households can receive assistance in Year 2. Assistance for each eligible households is assumed to be 6 to 12 months but not exceeding Security and Utility Deposits Subsidy Assumptions: Assumes 10 households can receive assistance in Year 1. Assumes 24 households can receive assistance in Year 2. HQS Inspections Assumptions: Assumes 20 inspections in Year 1 and 48 inspections in Year 2 at 100 per inspection. Assumes inspections every six months for each eligible household. Average of 16 hours per Housing Unit. Activities include inspection of unit, advocacy with landlord, agreements with landlord, travel time, review and approval, and follow-up. Income Eligbility Assumptions: Assumes 20 screenings in Year 1 and 48 screenings in Year 2 at 75 per screening. Assumes income eligibility screenings every six months for each adult and some households will have more than one adult. Average of 6 hours per adult with income. Activities will include documentation screening, verification and review, calculation of gross, adjusted, exclusions, City Inclusionary Funds and LMIAF Assumptions: Includes ineligible administrative costs under the HOME Program, such as Intake Assessment, Housing Search, Case Management, Self -Sufficiency, related Support Services Mercy House Exhibit G Housing Quality Standards (HQS) Inspection Checklist Inspection Checklist U.S. Department of Housing OMB Approval No 2577-0169 and Urban Development (exp 4/30/2014) Housing Choice Voucher Program Office of Public and Indian Housing Public reporting burden for this Collection of information is estimated to average 0.50 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number. Assurances of confidentiality are not provided under this collection. This collection of information is authorized under Section 8 of the U.S. Housing Act of 1937 (42 U.S.0 14370. The information is used to determine if a unit meets the housing quality standards of the section 8 rental assistance program. Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to collect the information required on this form by Section 8 of the U S Housing Act of 1937 (42 U S C 14370. Collection of the name and address of both family and the owner is mandatory The information is used to determine if a unit meets the housing quality standards of the Section 8 rental assistance program. HUD may disclose this information to Federal, State and local agencies when relevant to civil, criminal, or regulatory investigations and prosecutions It will not be otherwise disclosed or released outside of HUD, except as permitted or required by law Failure to provide any of the information may result in delay or rejection of family participation. Name of Family Tenant ID Number ;Date of Request (mmfddlyyyy) Inspector Neighborhood/Census Tract JDate ofInspection (mmldd/yyyy) Type of Inspection Date of Last Inspection (mmlddlyyyy) PHA A. General Information -- - ..------- --- Inspected Unit Year Constructed (yyyy) - -__` Housing Type (check as appropriate) Full Address (including Street, City County, State, Zip) D High Rise El Low Rise 3,4 stones C 1 Mobile Home Row House/GardenfTownhous Number of Children in Family Under s _ Semi Detached Duplex Shared Housing Owner `J Single Family Detached Name of Owner or Agent Authorized to Lease Unit Inspected 'Phone Number J Single Room Occupancy Owner Owner: Agent: _ Agent: Address of Owner or Agent Owner: , Agent: B. Summary Decision On Unit (To be completed after form has been filled out)_____�__-__.---____ Pass Fall Inconclusive Inspection Checklis Item Number of Bedrooms for Purposes of Number of Sleeping Rooms the FMR or Payment Standard No. 1. Living Room 1 1 Living Room Present 12 Electricity 1.3 Electrical Hazards Yes No In- Final Approval Pass Fail Conc. Comment Date (mm/dd/yyyy) 1.4 Security X 1.5 Window Condition ------------ X _ 1.6 Ceiling Condition X 1.7 Wall Condition 1 8 Floor Condition X ` Room Codes 1 = Bedroom or Any Other Room Used for Sleeping (regardless of type of room); 2 = Dining Room or Dining Area; 3 = Second Living Room, Family Room, Den, Playroom, TV Room; 4 = Entrance Halls, Corridors, Halls, Staircases; 5 = Additional Bathroom; 6 = Other HAPPY Software, Inc Page 1 of 7 form HUD-62680 (3/2001) ref Handbook 7420 8 Item No. 1�UvingRoom (Cont�uod) Yes No m' :I Final Approval ,*/ Cone.; Comment Date (mm/dd/yyyy) _ 1.9 Lead -Based Paint �� ! � �� � Not Applicable | | | Are all painted surfaces free of deteriorated� paint? nnct,modeteriorated surfaces exceed two If square feet per room and/or ismore than 10% of a component? 2. Kitchen 2.1 Kitchen Area Present 2.2 Electricity 2.3 Electrical Hazards 2-4 2.5 Security Window Condition 2.6 Ceiling Condition X 2.7 Wall Condition 2.8 Floor Condition 2.9 Lead -Based Paint NotApplicable Are all painted surfaces free of deteriorated If not, do deteriorated surfaces exceed two square feet per room and/or is more than 2A 0 Stove or Range with Oven 2.11 Refrigerator 2.12 Sink 2.13 Space for Storage, Preparation, and Serving of Food o. Bathroom 3.1 Bathroom Present 32 Electricity 3 3 Electrical Hazards 34 Security 3.5 Window Condition 3.6 Ceiling Condition 3.7 Wall Condition 18 Floor Condition Are all painted surfaces free of deteriorated nnot, uodeteriorated surfaces exceed two square feet per room and/or is more than 100% of a component? | | 3.10 Flush Toilet in Enclosed Room in Unit 3.11 Fixed Wash Basin or Lavatory in Unit 112 Tub or Shower in Unit 3.13 Ventilation HAPPY Software, Inc Page zox7 form nVo-5usVo(3/2oo1) Item 4. Other Rooms Used For Living and Halls Yes No 1 in- � I Final Approval Tass Fail Conc.' Comment --------- - ------ --------- Date (mmiddlyyyy) 41 Room Type Room Location Floor Level_ 42 Electricity/Illumination 43 Electrical Hazards 4.4 Security 4 5 Window Condition - ------ ----------- — --- ----- 4 6 Ceiling Condition 4.7 Wall Condition 48 Floor Condition 4.9 Lead -Based Paint Not Applicable Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? 7 4 10 Smoke Detectors 4 1 Room Type Room Location ----- ------ 4.2 Electricity/illumination Floor Level 4.3 Electrical Hazards 4 4 Security 4.5 Window Condition - ------ --- .. ....... .. --- ---- 4,6 Ceiling Condition 4.7 Wall Condition ---------- 4.8 Floor Condition 4.9 Lead -Based Paint Not Applicable Are all painted surfaces free of deteriorated i paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? 4.10 Smoke Detectors 41 Room Type 42 Electricity/Illumination 4 3 Electrical Hazards 4.4 Security 4 5 Window Condition 4.6 Ceiling Condition 4.7 Wall Condition 4.8 Floor Condition 4.9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? 4.10 Smoke Detectors Room Location Floor Level Not Applicable HAPPY Software, Inc Page 3 of 7 form HUD-52580 (3/2001) ref Handbook 7420.8 Item 4. Other Rooms Used For Living and Halls Yes ; No ' In- Final Approval No. Pass I Fail Conc.; Comment Date (mm/dd/yyyy) 41 Room Type Room Location Floor Level 4.2 ......_.r... Electricity/Illumination -------- -._._._._..__._ . ........................._......._........._.._..........._......_-... ( j 43 Electrical Hazards 44 Security —' 4.5 i Window Condition 46 Ceiling Condition 47 Wall Condition 4.8 Floor Condition 4.9 Lead -Based Paint Not Applicable Are all painted surfaces free of deteriorated i paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? j 4.10 Smoke Detectors 4, 1 Room Type Room Location Floor Level 42 Electricity/Illumination T-- 4.3 Electrical Hazards 44 Security - - _ ......................_.._._........_....._..__...__.... 4.5 Window Condition — 46 Ceiling Condition ! 47 Wall Condition 4.8 Floor Condition 49 Lead -Based Paint Not Applicable Are all painted surfaces free of deteriorated - paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? j 4 10 Smoke Detectors j 5. All Secondary Rooms ----- --------- - (Rooms -not used for living_ 5.1 None_X Go toPart 6— —. -- --- —� -- _ 5.2 Security 53 Electrical Hazards j 5.4 Other Potentially Hazardous Features I in these Rooms HAPPY Software, Inc Page 4 of 7 form HUD-52580 (3/2001) ref Handbook 7420.8 Item 6. Building Exterior Yes No In - Final Approval No. Pass Fail Conc.: Comment Date (mm/dd/yyyy) 6 1 Condition of Foundation 62 Condition of Stairs, Rails, and Porches X 6.3 Condition of Roof/Gutters 6.4 ------------ -------------- -------- Condition of Exterior Surfaces 65 Condition of Chimney 66 Lead Paint. Exterior Surfaces Not Applicable ------ ---- - Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed 20 square feet of total exterior surface area? 6 7 Manufactured Home. Tie Downs 7. Heating and Plumbing 7.1 Adequacy of Heating Equipment .... .. . .... ........ - - - - ------------- ---- -------- 7.2 Safety of Heating Equipment 7.3 Ventilation/Cooling 7.4 Water Heater 7.5 Approvable Water Supply ---- - --- --- 76 Plumbing X I 77 Sewer Connection 8. General Health and Safety 8.1 -- ----- . .... ... Access to Unit ------ 8.2 Fire Exits 8.3 Evidence of Infestation 8.4 Garbage and DebrisXI 8.5 Refuse Disposal ---------------------------- ------- - ------- - 8.6 Interior Stairs and Common Halls 8.7 Other Interior Hazards 8.8 Elevators -------- ------ 8.9 Interior Air Quality 8 10 Site and Neighborhood Conditions - - - -------- ---------- 8 11 Lead -Based Paint: Owner's Certifcat'on If the owner is required to correct any lead -based paint hazards at the property including deteriorated paint or other hazards identified by a visual assessor, a certified lead -based paint risk assessor, or certified lead -based paint inspector, the PHA must obtain certification that the work has been done in accordance with all applicable requirements of 24 CFR Part 35. The Lead -Based Paint Owner Certification must be received by the PHA before the execution of the HAP contract or within the time period stated by the PHA in the owner HQS violation notice. Receipt of the completed and signed Lead -Based Paint Owner Certification signifies that all HOS lead -based paint requirements have been met and no re-inslospection by the HOS inspector is required. HAPPY Software, Inc Page 5 of 7 form HUD-52580 (3/2001) ref Handbook 7420,8 C. Special Amenities (Optional) This Section is for optional use of the HA. It is designed to collect additional information about other positive features of the unit that may be present Although the features listed below are not included in the Housing Quality Standards, the tenant and HA may wish to take them into consideration in decisions about renting the unit and the reasonableness of the rent. Check/list any positive features found in relation to the unit. Living Room High quality floors or wall coverings Working fireplace or stove Balcony, patio, deck, porch Special windows or doors Exceptional size relative to needs of family ;Other. (Specify) 2. Kitchen Dishwasher Separate freezer Garbage disposal Eating counter/breakfast nook Pantry or abundant shelving or cabinets Double oven/self cleaning oven, microwave Double sink High quality cabinets jAbundant counter -top space Modern appliance(s) Exceptional size relative to needs of family Other: (Specify) 3. Other Rooms Used for Living High quality floors or wall coverings Working fireplace or stove Balcony, patio. deck, porch Special windows or doors J Exceptional size relative to needs of family r 'Other: (Specify) 4. Bath ;Special feature shower head Built-in heat lamp Cj Large mirrors r_ 1Glass door on shower/tub Separate dressing room [__:,Double sink or special lavatory r-i L j Exceptional size relative to needs of family _]Other: (Specify) 5. Overall Characteristics Storm windows and doors Other forms of weatherization (e.g , insulation, weather stripping) _ Screen doors or windows Good upkeep of grounds (i e., site cleanliness, landscaping, condition of lawn) r ! Garage or parking facilities Driveway Large yard Good maintenance of building exterior I Other: (Specify) 6. Disabled Accessibility Unit is accessible to a particular disability Disability D. Questions to ask the Tenant (Optional) 1. Does the owner make repairs when asked? Yes i� No 2. How many people live there? 3. How much money do you pay to the owner/agent for rent?_�_ 4 Do you pay for anything else? (specify)__.._.___________ 5. Who owns the range and refrigerator?(insert O = Owner or T = Tenant) Range Refrigerator 6. Is there anything else you want to tell us? (specify) Yes �I No Microwave _ I Yes __... No HAPPY Software, Inc Page 6 of 7 form HUD-52580 (3/2001) ref Handbook 7420.8 E. Inspection Summary/Comments (Optional) Provides a summary description of each item which resulted in a rating of "Fail' or `Pass with Comments." — - - - - - --- ----------------- Tenant ID Number Inspector Name Date of Inspection Address of Inspected Unit (mmldd/yyyy) Type of Inspection Item Number Reason for "Fail" or "Pass with Comments" Rating I hereby certify that the above comments from the inspection report are true and accurate. Tenant signature(s) and Date HAPPY Software, Inc Page 7 of 7 form HUD-52580 (3/2001) ref Handbook 7420.8 MERCY-2 OP ID: SD .4CORO CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 06/18/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Dufour Insurance Services, LLC 5611 Littler Drive Huntington Beach, CA 92649 Stephanie Dufour CONTACT NAME: Stephanie Dufour AICNo Ext :714-369-2998 ac No): 714-840-6357 E-MAIL ADDRESS: p V Ste hanie/,,�dufourinsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Great American Insurance Compa 16691 INSURED Mercy House Living Centers P.O. Box 1905 Santa Ana, CA 92702 INSURER e:Great American Insurance Compa 16691 INSURER C: NOVA Casualty Company 42552 INSURER D:Great American Insurance Group 37532 INSURER E: Philadelphia Indemnity 18058 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD/YYYY MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 100,000 A X COMMERCIAL GENERAL LIABILITY Y Y PAC426088203 05/02/2018 05/02/2019 CLAIMS -MADE 7 OCCUR MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 A X Prof. Liability PAC426088203 05/02/2018 05/02/2019 A X Sex Abuse/Miscond PAC426088203 05/02/2018 05/02/2019 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY PRO LOC Ded•- $0 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ A ANY AUTO Y Y CAP 188045404 05/02/2018 05/02/2019 ALL OWNED X SCHEDULED AUTOS AUTOS X HIRED AUTOS X NON -OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE PERACCIDENT $ 130,000 Comp/Coll Ded. $ 50 X UMBRELLA LIAB i X OCCUR EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,00 B EXCESS LIAB CLAIMS -MADE Y Y UMB 426088303 05/02/2018 05/02/2019 DED X RETENTION $ 10000 $ C E WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N OFFICER/MEMBER EXCLUDED? ❑ (Mandatory In NH) NIA Y CF1-WK-10000043-00 (ACCIDENT)PHLY78928850 02/08/2018 11/21/2017 02/08/2019 11/21/2018 X WC STATU- X OTH- TORY LIMITS ER E L EACH ACCIDENT $ 1,000,00 EL DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below I I I E L. DISEASE - POLICY LIMIT $ 1,000,000 D Cyber Liability Y Y NLP3642944 01/29/2018 01/29/2019 Per Occ 1,000,000 E D&O/ EPLI Y Y PHSD1173663 10/17/2018 10/17/2019 Aggregate 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) The City of Huntington Beach, its agents, officers, employees and volunteers are named as Additional Insured as respects the operations of Named Insured per attached endorsement. This insurance is primary and noncontributory. Blanket Waiver of Subrogation applies on liability and workers comp policies. 10 day notice of cancellation. APP OVEDASTOFORM ICATE City of Huntington Beach 2000 Main Street Huntington Beach, CA 92648 CITY OF HUKi •�N":! YN pCNl-n SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD MERCY-2 OP ID: SD '44ccw& CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 09/04/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Dufour Insurance Services, LLC 5611 Littler Drive CONTACT Stephanie Dufour PHONE 714-369-2998 FAR No : 714-840-6357 A/C No Ed): SS: Stephanie@dufourinsurance.com Huntington Beach, CA 92649 Stephanie Dufour —ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Great American Insurance Compa 16691 INSURED Mercy House Living Centers P.O. Box 1905 Santa Ana, CA 92702 INSURER B: Great American Insurance Compa 16691 INsuRERc:NOVA Casualty Company 42552 INSURER D: Great American Insurance Group 37532 INSURER E: Philadelphia Indemnity 18058 INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE DDL SUER POLICY NUMBER MM/ D�YY MFF M DD� XP YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO HEN FU PREMISES Ea occurrence $ 100,000 A X COMMERCIAL GENERAL LIABILITY Y Y PAC426088203 05/02/2018 05/02/2019 CLAIMS -MADE a OCCUR MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 A X Prof. Liability PAC426088203 05/02/2018 05/02/2019 A X Sex Abuse/Miscond PAC426088203 05/02/2018 05/02/2019 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER'. PRODUCTS - COMP/OP AGG $ 2,000,000 Ded.- $0 $ X POLICY PRO LOC JEC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ A ANY AUTO Y Y CAP 188045404 05/02/2018 05/02/2019 ALL OWNED X SCHEDULED AUTOS ATOS U X HIRED AUTOS X NON -OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE PER ACCIDENT $ 130,00 Comp/Coll Ded. $ 50 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,000 B EXCESS LIAB CLAIMS -MADE Y Y UMB 426088303 05/02/2018 05/02/2019 DED X RETENTION $ 10000 $ C E WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory In NH) NIA Y CF1-WK-10000043-00 (ACCIDENT) PHLY78928850 02/08/2018 11/21/2017 02/08/2019 11/21/2018 WC STATU- T H- X TORY LIMITS X ER E.L. EACH ACCIDENT $ 1,000,000 E.L DISEASE -EA EMPLOYEE $ 1,000,000 If yes, descnbe under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT $ 1,000,000 D Cyber Liability Y Y NLP3642944 01/29/2018 01/29/2019 Per Occ 1,000,000 E D&O/ EPLI Y Y PHSD1173663 10/17/2018 10/17/2019 Aggregate 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The City of Huntington Beach, its agents, officers, employees and volunteers are named as Additional Insured as respects the operations of Named Insured per attached endorsement. This insurance is primary and noncontributory. Blanket Waiver of Subrogation applies on liability and workers comp policies. 10 day notice of cancellation. I:EK I II-IL;A I t HULUtK City of Huntington Beach 2000 Main Street Huntington Beach, CA 92648 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD MERCY-2 OP ID: SD , Ili- CERTIFICATE OF LIABILITY INSURANCE � DATE (MM/DD/YYYY) 09/04/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Dufour Insurance Services, LLC 5611 Littler Drive Huntington Beach, CA 92649 Stephanie Dufour CONTACT NAME: Stephanie Dufour PHONE 714-369-2998 FAX No): 714-840-6357 A/c No E:t ADDRESS: Stephanie@dufourinsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:Great American Insurance Compa 16691 INSURED Mercy House Living Centers P.O. Box 1905 Santa Ana, CA 92702 INSURERB:Great American Insurance Compa 16691 INSURER C: NOVA Casualty Company 42552 INSURER D:GreatAmerican Insurance Group 37532 INSURERE:Philadelphia Indemnity 18058 INSURER F C0\/FRAr.F3 CFRTIFICATF NUMBER- REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUMBER EFF MM DDY EXP POLICY DD/YYYY MM LIMITS A A A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 7 OCCUR X Prof. Liability PAC426088203 PAC426088203 PAC426088203 05/02/2018 05/02/2018 05/02/2018 05/02/2019 05/02/2019 05/02/2019 EACH OCCURRENCE $ 1,000,000 PREMISES Eaoccurrence $ 100,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,00 X Sex Abuse/Miscond GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER X POLICY PRO LOC PRODUCTS -COMP/OP AGG $ 2,000,000 Ded.- $0 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS X AUTOS NON -OWNED X HIREDAUTOS X AUTOS CAP 188045404 05/02/2018 05/02/2019 COEaMBINED adent SINGLE LIMIT ac $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE PERACCIDENT $ 130,00 Comp/Coll Ded. $ 50 B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE UMB 426088303 05/02/2018 05/02/2019 EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,000 DED X RETENTION $ 10000 $ C E WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER R EXCLUDED? In N NH) (Mandatory in If yes, describe under DESCRIPTION OF OPERATIONS below NIA CF1-WK-10000043-00 ACCIDENT PHLY78928850 () 02/08/2018 11/21/2017 02/08/2019 11/21/2018 WC STATU- O R X TORY LIMITS X ER EL EACH ACCIDENT $ 1,000,000 E L DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1 $ 1,000,000 D E Cyber Liability D&O/ EPLI NLP3642944 PHSD1173663 01/29/2018 10/17/2018 01/29/2019 10/17/2019 Per Dee 1,000,000 Aggregate 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) aNit11=11111:Lei 41111Ja:i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PAC4260882-03 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): I Location(s) Of Covered Operations The City of Huntington Beach, its agents, officers, employees Per contract and volunteers Information required to complete this Schedule if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertis- ing injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 Copyright, Insurance Services Office, Inc., 2004 Page 1 of 1 0 ATTACHMENT #3 City of Huntington Beach 2000 Main Street ♦ Huntington Beach, CA 92648 (714) 536-5227 ♦ www.huntingtonbeachca.gov Office of the City Clerk Robin Estanislau, City Clerk October 8, 2018 Families Forward Attn: Madelynn Hirneise 8 Thomas Irvine, CA 92618 Dear Ms. Hirneise: Enclosed is a copy of the fully executed "Home Recipient Agreement between the City of Huntington Beach and Families Forward." Sincerely, Robin Estanislau, CIVIC City Clerk RE:ds Enclosure Sister Cities: Anjo, Japan ♦ Waitakere, New Zealand HOME RECIPIENT AGREEMENT BETWEEN THE CITY OF HUNTINGTON BEACH AND FAMILIES FORWARD (Tenant Based Rental Assistance) This HOME RECIPIENT AGREEMENT (Tenant Based Rental Assistance) ("Agreement") is made and entered into as of (I 1201$ ("Effective Date") by and between the CITY OF HUNTINGTON BEACH, a municipal corporation and charter city ("City"), and FAMILIES FORWARD, a California nonprofit public benefit corporation ("Subrecipient"). RECITALS A. City is a California municipal corporation and charter city under the laws of the State of California. B. City has applied for and received funds ("HOME Funds") from the United States Department of Housing and Urban Development ("HUD'') pursuant to the HOME Investment Partnerships Act and HOME Investment Partnerships Program, 42 U.S.C. §12701, et seq., and the implementing regulations set forth in 24 CFR § 92.1, et seq. (together, "HOME Program") for the purposes of strengthening public -private partnerships to provide more affordable housing, and particularly to provide decent, safe, sanitary, and affordable housing for very low income and lower income citizens of Huntington Beach in accordance with the HOME Program. As used herein, the HOME Program includes the HUD Final Rule set forth at 78 FR 142, adopted July 24, 2013, which adopts substantial amendments to the HOME Program regulations set forth at 24 CFR Part 92. C. City is currently implementing a coordinated 21-month strategy and program to provide financial assistance to eligible extremely low, very low and lower income families and households to enable such households to secure housing available at an affordable housing cost in the City. D. City has developed a Tenant Based Rental Assistance Program to assist families with at least one child under the age of 19 in the City to transition into permanent, housing. Fifty percent (50%) of new clients referred will be from the Huntington Beach Homeless Task Force. Up to 50% of families who are literally homeless will be referred into the TBRA through Orange County's Coordinated Entry System. E. City wishes to engage the Subrecipient to assist the City in utilizing HOME Funds to provide tenant based rental assistance, security deposit assistance and utility assistance for families consisting of at least one child under the age of 19 experiencing homelessness or at risk of homelessness who are 18-6744/185593/mv residents of the City, in accordance with the terms and provisions set forth in this Agreement. NOW, THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows: ARTICLE 1 SCOPE OF SERVICES 1.1 Scope of Services. During the entire Term (defined below) of this Agreement, Subrecipient shall administer the City's HOME -funded Tenant Based Rental Assistance Program ("TBRA Program"), all in accordance with this Article 1 (collectively, the "Services") and the TBRA Program Operating Guidelines attached hereto as Exhibit A. In connection with the Services, Subrecipient shall comply with all requirements of the HOME Program, this Agreement and all applicable federal, state and local laws and regulations. Subrecipient shall further take all reasonable actions necessary to enable City to comply with City's obligations under the HOME Program relating to the TBRA Program. The Subrecipient shall perform the Services set forth in this Article 1 in furtherance of the TBRA Program. 1.2 Program Participation. (a) Marketing and Outreach. Subrecipient shall undertake affirmative marketing and outreach activities to find prospective Eligible Households interested in the TBRA Program, all in accordance with HUD's Affirmative Fair Housing and Marketing regulations and the City's Affirmative Fair Housing Marketing Plan, when adopted. Subrecipient shall describe its marketing and outreach efforts in quarterly progress reports submitted to the City under this Agreement, as described in Exhibit B. (b) Program Participation. Families with at least one child under the age of 19 who are literally homeless or at risk of homelessness and residents of Huntington Beach will be referred into the TBRA through the Huntington Beach Homeless Task Force (HTF) and Orange County's Coordinated Entry System. (c) Waiting List. Subrecipient will obtain eligible families through Orange County's Coordinated Entry System. If there are more eligible families than program slots available in the TBRA program, then Families Forward will work within the Coordinated Entry System to connect eligible households to appropriate services within Orange County. (d) Intake Process. A prospective Eligible Household who is literally homeless shall meet with the Subrecipient to fill out an Initial Qualification Document in substantially the form attached as Appendix A to the TBRA Program Operating Guidelines, including an income calculation based on three months of source documentation (bank account statements, pay stubs, etc.) to prequalify such prospective Eligible Household. Subrecipient shall then meet with prequalified l 8-6744/l 85593/mv 2 Eligible Households to determine and verify their qualifications and eligibility for assistance under the TBRA Program, provide such prequalified Eligible Households with the TBRA Program application and other documentation described below, assist prospective Eligible Households with the completion of the application and gross income calculation worksheet and qualify Eligible Households for the TBRA Program. Subrecipient shall provide every prequalified Eligible Household with all of the following documentation. (i) Fifty percent (50%) of new clients will be referred by the Huntington Beach Homeless Task Force. Deputy Director has the authority to waive the requirement. (ii) TBRA Application in the form attached to the TBRA Program Operating Guidelines as Appendix B, or as otherwise approved in writing by the Deputy Director of Business Development on behalf of the City ("Deputy Director"). The TBRA Application shall solicit information regarding each applicant household's income and assets, household size and composition (number of children and adults), names of household members, Housing Unit (defined below) size and location preferences, specific needs and considerations, and a race/ethnicity survey. Examples of acceptable documental to confirm recent residency include: - Copy of previous lease - Copy of previous utility bill - Written confinnation of residency from a previous landlord, or proof of residency in transitional living facility - Copy of school records confirming previous residency Examples of proof of strong ties to the community include: - Current residency of an immediate family member — mother, father, sibling, child, or grandparent - Proof that the individual and/or their dependent(s) attended K-12 school in Huntington Beach - Written acknowledgement from the Huntington Beach Police Department or Homeless Task Force that individual has been living in Huntington Beach's streets for 18 months. Special Circumstances — the following categories of individuals may meet the definition of Huntington Beach Homeless Resident: - Homeless individuals that are "Medically Compromised" - Elderly homeless individuals (60+) - If the Huntington Beach Police Department (HBPD) or Homeless Task Force (HTF) staff believe that an individual's well-being will be severely compromised by living on the street and/or if the individual is a chronic nuisance or offender who's presence in Huntington Beach poses a threat to others or in a consistent drain on public resources, then a team composted 18-6744/185593/mv 3 of HBPD/HTF may, on a case -by -case basis, determine that such individual qualifies as a HB Homeless Resident. (iii) Declaration of Homelessness Status, as appropriate, in the forms attached to the TBRA Program Operating Guidelines as Appendix C. (iv) Rental Assistance Contracts for the landlord and the Eligible Households, in the forms attached to the TBRA Program Operating Guidelines. Income Calculation Form in the form attached to this Agreement as Exhibit C. (v) Household Budget Worksheet in the form attached to this Agreement as Exhibit D. (vi) Lead -Based Hazard Information Pamphlet "Protect Your Family from Lead in Your Home" attached to this Agreement as Exhibit E. A prospective Eligible Household who is at -risk of homelessness shall meet with the Subrecipient to determine and verify their qualifications and eligibility for rental, utility or security deposit funding assistance. An income calculation based on three months of source documentation (bank account statements, pay stubs, etc.) to prequalify such prospective Eligible Household will be conducted. Eligible households receiving assistance will be required to provide: (i) Completed Communication Disclosure and Consent to Exchange Information Form (ii) Completed Registration Form (iii) State -issued identification for each adult in household (iv) Birth certificate, school ID, last report card, immunization record OR Social Security card for each child in household (v) Copy of the lease (vi) Copy of landlord's W-9 form. Subrecipient will communicate with the landlord to mediate eviction prevention and provide negotiated financial assistance directly to the landlord to halt the eviction process. The assistance will be a one-time issuance and must result in halting the current eviction process. Income documentation must verify the family's ability to maintain rental payments going forward. Families must also be an Eligible Household as defined in Section 1.3(a). Under Section 1.7, termination of assistance must also include lack of qualification as an Eligible Household. The indemnity should exclude intentional as well as negligent acts to City. (d) Guidance for Eligible Households. Subrecipient shall meet with prospective Eligible Households throughout the application process and shall continue to meet with and counsel each Eligible Household regarding the TBRA Program, the 18-6744/185593/mv 4 Eligible Household's responsibilities as participants of the TBRA Program, and the goals and objectives of the TBRA Program. 1.3 Determination of Eligibility. Subrecipient shall qualify all Eligible Households in accordance with the selection criteria described in this Section. Further, for all Eligible Households Subrecipient shall implement the selection criteria and policies in compliance with the City's Consolidated Plan and the City's housing needs and priorities. (a) Eligible Household. As used in this Agreement, "Eligible Household" refers to extremely -low, very -low, and low-income households (up to 80% AMI) that are (i) currently residents of the City of Huntington Beach, and (i) currently homeless or at risk of homelessness and (iii) include at least one child (under the age of 19). It is anticipated that the Eligible Households assisted pursuant to the TBRA Program will be the same households assisted pursuant to the ESG Agreement. (i) As used in this Agreement, "at risk of homelessness" refers to a household that is at risk of being evicted due to an economic hardship in paying rent or staying current with rent, as determined in accordance with the ESG Program. (ii) For purposes of determining eligibility for the TBRA Program, a prospective Eligible Household's (or for continuing compliance, a participating Eligible Household's) gross annual income shall be determined in accordance with 24 CFR 5.609, with the allowable exclusions from income established at 24 CFR 5.611. For purposes -of this Agreement, annual income means the gross amount of income from all sources, including assets, for all adult household members that is anticipated to be received prospectively during the 12-month period following the date of application and before any deductions are taken (and for a participating household, income anticipated for the 12 months following verification described in § 1.3(b)(11) below.) When collecting income verification documentation, Subrecipient may also consider any likely changes in income. (iii) For purposes of this Agreement and the TBRA Program, income limits for extremely -low, very -low and low income households are established annually by HUD for the Orange County income limit area. (b) Income Verification. (i) Initial Verification. To determine if TBRA Program applicants (collectively, "Applicants") are income -eligible, Subrecipient must verify each Applicant's household income using source documentation such as wage statements, interest statements, unemployment compensation statements, and bank account statements, and other documentation types 18-6744/185593/mv 5 approved by HUD. Once an initial income verification is completed, the Subrecipient is not required to re-examine the Eligible Household's income unless six months has elapsed before assistance is provided. (ii) Annual Eligibility Verification. Subrecipient shall annually re -certify income and re -qualify each Eligible Household. (c) Verification of Eligibility. Subrecipient shall collect and examine source documentation submitted by the Applicant to verify the identity of the members of the Eligible Household and that the Eligible Household includes at least one child (under 19 years old). Verification of resident ties to the City may include: former leases, former utility bills, eviction notices, school report cards, state issued identification with City address, pay check stubs with former address, establishment of current residency of an immediate family. Subrecipient shall make a determination that the Eligible Household is currently experiencing homelessness or is at risk of homelessness, as defined in the ESG Program (24 CFR 576.2), based on caseworker observations and certification, other homelessness provider certification, eviction notice or Applicant self -certification. (d) Written Notice of Eligibility Determination. Subrecipent shall provide written notice to each Applicant stating whether such Applicant was determined to be eligible for assistance under the TBRA Program. Applicants determined to be ineligible for TBRA Program assistance shall have an opportunity to appeal the determination to the Subrecipient's Executive Director. If the issue is not resolved, the case will be referred to the Deputy Director of Economic Development. The definitions of "homelessness" and "at risk of homelessness" under the ESG Program (24 CFR 576.2) are applicable to this Agreement. 1.4 Selection of Housing Units. (a) Housing Unit Selection. Subrecipient shall assist Eligible Households with finding and selecting an appropriate housing unit (each a "Housing Unit") that meets federal housing quality standards ("HQS") or such other standards as may be made applicable to the TBRA Program by HOME Program statutes and/or regulations, specifically including Uniform Physical Condition Standards (UPCS), and that satisfies the requirements of the TBRA Program, HOME Program and this Agreement. Eligible Households shall also be entitled to find a Housing Unit for themselves, subject to compliance with the requirements of the TBRA Program, HOME Program and this Agreement; however, the parties anticipate that in most cases, Subrecipient shall be responsible for locating and qualifying an appropriate Housing Unit for occupancy by each Eligible Household. Subrecipient may refer Eligible Households to appropriate Housing Units but may not require an Eligible Household to select a particular Housing Unit. Subsidy Payments shall only be provided in connection with the rental of a qualified Housing Unit located in the City, unless Subrecipient 18-6744/ 185593/mv 6 documents reason for selecting housing outside the City or documents specific efforts to unsuccessfully locate housing within the City for the participant. Subsidy Payments under this Agreement are portable within the City. Subsidy payments under this Agreement are portable within the City. Subrecipient's obligations under this Section 1.4 apply to each Housing Unit to be occupied by an Eligible Household receiving Subsidy Payments hereunder. (b) Housing Unit Size; Occupancy Standards. Housing unit selection shall comply with the following "Occupancy Standards" for the applicable Eligible Household: No more than two persons per bedroom plus one may occupy the Housing Unit. Thus, no more than three persons may occupy a one -bedroom Housing Unit, no more than five persons may occupy a two bedroom Housing Unit; no more than seven persons may occupy a three bedroom Housing Unit; no more than nine persons may occupy a four bedroom Housing Unit. (c) Property Inspection. Prior to occupancy of any Housing Unit by an Eligible Household, and again during the annual (or more often) verification process, Subrecipient shall cause a certified HQS inspector to inspect each Housing Unit occupied or to be occupied by an Eligible Household to ensure the Housing Unit complies with HQS as set forth in the HOME Program, including without limitation 24 CFR 92.251, as well as all applicable state and local codes and ordinances, including zoning ordinances. Subrecipient shall provide the City with documentation of each HQS inspector's certification. Each HQS inspection shall include all of the following: (i) Verification of the age of the Housing Unit; (ii) Complete HQS Inspection Checklist in the form attached as Exhibit G, including a rating for the Housing Unit of Pass, Pass with Comment, or Fail; (iii) Lead -based hazard assessment, dissemination of lead -based hazard information pamphlet and disclosure form and lead -based hazard reduction activities, if required by the HOME Program or applicable federal, state and/or local laws; (iv) Adequate opportunity for the Landlord (defined below) to correct any deficiencies indicated in the HQS Inspection Form to bring the Housing Unit into compliance with HQS requirements; (v) Verification that occupancy by the Eligible Household will comply with the Occupancy Standards set forth in Section 1.4(b); and 18-6744/185593/mv 7 (vi) Certification of rent reasonableness regarding the rent being charged for the Housing Unit based on comparable non -assisted Housing Units in the same area. Subrecipient shall perform the rent reasonableness review subject in each instance to review and approval by the City. City may elect to perform the rent reasonableness reviews on behalf of Subrecipient by providing written notice to Subrecipient. The rent charged under the written lease agreement for the Housing Unit shall conform to the rent reasonableness standard pursuant to the TBRA Program Operating Guidelines, which is based on local market conditions. The contract rent for Housing Units that are restricted to an affordable rent by agreement with the City or by regulation or ordinance, or otherwise, shall be likewise restricted to such affordable rent in accordance with the contractual, statutory or regulatory restrictions governing the permitted rents for such Housing Units and the Rental Assistance Subsidy Payment shall be limited and calculated accordingly, as described in Section 1.5(a), below. (d) Coordination with Landlords. (i) Landlord Guidance. Subrecipient shall provide guidance to the property owners, property owners' representatives, or property management companies hired by property owners (each a "Landlord" and collectively referred to as "Landlords") participating in the TBRA Program regarding the TBRA Program requirements and procedures that impact Landlords. (ii) Landlord Agreement. Subrecipient shall enter into a Landlord Agreement with each participating property owner/Landlord in substantially the form attached to the TBRA Program Operating Guidelines as Appendix E. The Landlord Agreement will establish the Subsidy Payments to be made by Subrecipient on behalf of the Eligible Household as well as the Eligible Household's initial share of the contract rent. The Landlord Agreement shall further establish the terms and conditions under which the Subsidy Payments shall be paid to the Landlord for the applicable Housing Unit, including applicable HOME Program requirements. The Landlord Agreement shall have an initial term of 6-12 months, subject to extensions approved by Subrecipient and City (as applicable) pursuant to the TBRA Program Operating Guidelines. (iii) Tenant Protection Agreement. Subrecipient shall require each Landlord to enter into a lease agreement with a term of 12 months with any Eligible Household occupying a Housing Unit owned and/or managed by such Landlord, which lease agreement shall include a Tenant Protection Agreement in substantially the form attached to the TBRA Program Operating Guidelines as Appendix F, or an updated form of Tenant Protection Agreement as may be prepared and provided by the City to the 18-6744/185593/mv 8 Subrecipient, and then by Subrecipent to Landlord. The Tenant Protection Agreement shall be executed in connection with the lease agreement between the Landlord and Eligible Household. The Tenant Protection Agreement will prohibit the inclusion of prohibited lease terms listed at 24 CFR 92.253; confirm the Landlord's obligation to maintain the Housing Unit in accordance with HQS, as established at 24 CFR 982.401; and prohibit discrimination by the Landlord against the Eligible Household. Subrecipient will review the lease agreement to confirm its compliance with state law and all HOME Program requirements. Subrecipient shall require the Landlord and Eligible Household to enter into a lease agreement that complies with state law, HOME requirements, and City requirements. 1.5 Subsidy Payments. Subrecipient shall make rent payments, security deposit payments and/or utility deposit payments, as applicable (collectively, the "Subsidy Payments"), to Landlords and/or to utility providers, as applicable, on behalf of Eligible Households. Subsidy payments must be provided in accordance to the Subrecipient's TBRA Program Operating Guidelines. Eligible Households are not expected to repay Subsidy Payments received pursuant to the TBRA Program. Except as may be permitted by the HOME Program, Subrecipient's sole remedy in the event of noncompliance or breach by an Eligible Household shall be non -renewal of assistance under the TBRA Program. (a) Rental Assistance Calculation. Subrecipient shall calculate the "Rental Assistance" payments to be paid on behalf of each Eligible Household under this Agreement. The initial household rent is equivalent to the maximum subsidy amount allowed under the HOME regulations and is calculated as the difference between 30% of the Eligible Household's gross monthly income and the payment standard for the size of the unit. (b) Payment Standards. Subrecipient must use the City's current payment standards as set forth in the Rent Reasonable Standards attached to the TBRA Program Operating Guidelines as Appendix G. The Housing Authority's payment standards represent the cost of rent and utilities for moderately priced units in Huntington Beach. Payment standards are established by bedroom size. (c) Utility Allowance. When utilities are included in the cost of renting a unit, that is, the owner assumes responsibility for payment for all utility services, the Eligible Households entire share of the housing costs will go directly to the owner. When the cost of utilities is not part of the rent, that is, the Eligible Household is directly responsible for payment of utility services, the Eligible Household's initial share will be determined by subtracting a utility allowance from 30% of the Eligible Household's gross monthly income. The Subrecipient must use the County of Orange's Housing Authority's Utility Allowance Schedule attached to the TBRA Program Operating Guidelines as Appendix H. 18-6744/185593/mv 9 (d) Term, 12. The Subrecipient will provide rental assistance for an initial term of 3- 12 months, which can be extended in 3-6 intervals, up to a total of eight times, for a cumulative term of up to 24 months. Extensions will be granted at the discretion of the Subrecipient and shall be based on continued program compliance and ongoing need. The Subrecipient will evaluate ongoing need. (e) Security Deposit Assistance. Subrecipient may provide security deposit assistance to each Eligible Household. It is anticipated that Subrecipient shall provide Security Deposit Assistance to each Eligible Household in an amount no greater than 2 months' rent. The lease agreement must provide that the security deposit is refundable in accordance with state law. Security deposit refunds shall be provided by the Landlord directly to the Eligible Household. Any disputes involving the return, or lack thereof, of a security deposit shall be settled by Eligible Household and landlord, as provided for in the lease. (f) Utility Deposit Assistance. Subrecipient may provide utility deposit assistance on behalf of each Eligible Household. It is anticipated that the Subrecipient will provide utility deposit assistance to each Eligible Household in the full amount of any utility deposit required for electricity, gas, and/or water service to the utility provider when needed to assist the Eligible Household in establishing tenancy. Utility deposit assistance may be provided only if the following requirements are met: (1) Utility deposit assistance is only available where rental assistance and/or security deposit assistance are also being provided. (ii) Utility deposit assistance shall be paid directly to the Landlord or utility provider, as applicable, on behalf of the Eligible Household. Utility deposit refunds shall be returned directly to the Eligible Household. 1.6 Administrative Cost Reimbursements. The City will reimburse the Subrecipient for allowable costs incurred in administering the TBRA Program, which are associated with the detennination of income eligibility, pursuant to 24 CFR 92.203, and property inspections under HQS, codified per 24 CFR 982.401. Administrative costs incurred in administering the TBRA Program that are ineligible under the HOME Program will be reimbursed from a non -HOME Program funding source, or Inclusionary Funds. The administrative costs to be reimbursed from the Inclusionary Funds include Intake Assessments, Housing Search, Case Management, Self -Sufficiency and related services and overhead. 18-6744/185593/mv 10 1.7 Termination of Assistance and Returning Eligible Households. (a) Termination of Rental Assistance. Subrecipient may terminate assistance under the TBRA Program for any of the following reasons: (i) Eligible Household is evicted from the Housing Unit based on behavioral issues or unlawful activity; (ii) Eligible Household has violated TBRA Participant Program Guidelines; (iii) Eligible Household will be assisted by another rental assistance program such as the Section 8 Tenant -Based or Project -Based Programs. Participation in any other rental assistance program is considered a duplicative subsidy therefore all HOME funded rental assistance must be terminated. (iv) Eligible Household has successfully graduated from the TBRA Program. 1.8 Returning Eligible Households. As needed, Eligible Households may be allowed to return to the program for rental assistance. A determination to allow re-entry shall be based on the following criteria: (i) Eligible Households must have left the program in good standing. To be in good standing, Eligible Households must have been engaged in their case management plan, voluntarily left the program (not in lieu of termination) or have been released because their household income exceeded eligibility limits. In general, Eligible Households will not be allowed to re-enter the program if they were terminated for non-compliance. (ii) At the discretion of the Subrecipient, a request for re -admission from a prospective Eligible Household previously terminated due to non- compliance may be considered when compelling reasons exist. In such cases, re -admission will require concurrence from the City. (iii) Eligible Households may return so long as the previous rental assistance did not exceed 24 months. Cumulatively, Eligible Households may not receive rental advice for more than a cumulative period of 24 months unless such assistance is permitted by the HOME Program and approved by the City. 1.9 Additional Requirements. (a) Self -Sufficiency Program. Subrecipient shall require each Eligible Household receiving Subsidy Payments from the Subrecipient to participate in a "Self - Sufficiency Program" administered by Subrecipient in accordance with the ESG 18-6744/185593/mv I I Agreement and the Case Management and Self Sufficiency Program Policies and Procedures attached to the TBRA Program Operating Guidelines as Appendix J. Failure of an Eligible Household that is already receiving Subsidy Payments to participate in the Self -Sufficiency Program shall not be grounds for termination of the Subsidy Payments, but may be grounds for non -renewal of Subsidy Payments upon expiration of the subsidy term. (b) No Fees. Subrecipient may not charge fees to any Eligible Household for the Services, Subsidy Payments, Self -Sufficiency Program or other services or assistance to be provided to Eligible Households under this Agreement. 1.10 Schedule of Performance. Subrecipient shall use its best efforts to perform the Services in accordance with the following schedule: (a) Affirmative marketing and outreach activities required by this Agreement shall commence immediately upon execution of this Agreement. (b) Subrecipient shall qualify Eligible Households, conduct HQS inspections, approve Housing Units, and move Eligible Households into approved Housing Units in accordance with the following milestone schedule: (i) Subrecipient shall process intake paperwork for and verify eligibility for TBRA Program assistance ("Enroll") for not fewer than 15 Eligible Households per year following execution of this Agreement. As program income becomes available and/or additional HOME Funds are contributed to the TBRA Program, Subrecipient shall use diligent efforts to enroll additional Eligible Households within not more than three (3) months following written notice from the City that such additional funds are expected to become available. (ii) Subrecipient shall assist each Enrolled Eligible Household in finding an appropriate Housing Unit and shall conduct an HQS inspection of such Housing Unit, all within two (2) months following Enrollment of such Eligible Household. (iii) Subrecipient shall commence providing Subsidiary Payments on behalf of each Eligible Household and shall assist each Eligible Household to move into an HQS-inspected and approved Housing Unit, all within three (3) months following Enrollment of such Eligible Household. (c) Subrecipient shall engage each Eligible Household in case management services and a self-sufficiency plan immediately upon Enrollment of such Eligible Household, whether or not such Eligible Household has yet moved into a Housing Unit and received the benefit of Subsidy Payments hereunder. Subrecipient will provide monthly updates to City staff about participant status and self-sufficiency plan progress. 18-6744/185593/mv 12 1.11 City Oversight and Approval Rights. City shall have the right, by written notice to Subrecipient at any time during the Term of this Agreement, to require City review of any of the Services to be performed by Subrecipient hereunder, including for example income determinations, qualification of applicants as "Eligible Households," qualification of Housing Units, determination of reasonable rents, etc., to ensure compliance with the TBRA Program, the HOME Program, or other applicable requirements. ARTICLE 2 TERM 2.1 Term. Services of the Subrecipient under this Agreement shall start on 10/1/2018 and end on the earlier to occur of (i) 6/30/2020 or (ii) the date the full amount of HOME Funds available under Section 3.2(a) below has been disbursed to Subrecipient and expended by Subrecipient to provide Subsidy Payments pursuant to this Agreement ("Term"), unless this Agreement is earlier terminated pursuant to Section 8.3. The Term of this Agreement and the provisions herein shall be further extended to cover any additional time period during which the Subrecipient remains in control of HOME Funds or other HOME assets, including program income. ARTICLE 3 BUDGET AND PAYMENTS 3.1 Budget. Subrecipient has submitted a budget to City for approval ("Budget"), which sets forth the estimated timing and use of the HOME Funds contributed by the City pursuant to this Agreement. The Budget is attached hereto as Exhibit F. Any amendments to an approved Budget for the Services must be approved by the City's Deputy Director or his or her authorized designee. In the event this Agreement is extended past the initial Term or any additional moneys will be contributed to the TBRA Program by City pursuant to this Agreement, Subrecipient shall prepare and submit to the Deputy Director for approval an updated Budget for such additional moneys. Subrecipient shall prepare a Budget, for approval by Deputy Director, for each year during which this Agreement remains in effect. The City may require a more detailed line item breakdown of the Budget than the one contained herein, and the Subrecipient shall provide such supplementary information about the Budget in a timely fashion in the form and content prescribed by the City. 3.2 Reimbursement of Subsidy Payments. City shall reimburse Subrecipient for Subsidy Payment actually disbursed to or on behalf of Eligible Households pursuant to this Agreement and in accordance with line items on the approved Budget or as otherwise approved by the City's Deputy Director. City shall have no obligation to reimburse Subrecipient for ineligible administrative costs or expenses incurred by Subrecipient to manage or implement the TBRA Program or this Agreement, for the cost of social or supportive services provided to Eligible Households hereunder, or for any other costs or expenses incurred by Subrecipient in connection with its activities under this Agreement. City's payment obligations hereunder shall be limited to the actual amount of Subsidy Payments disbursed by Subrecipient and eligible administrative costs in accordance with 18-6744/185593/mv 13 the terms of this Agreement and the approved Budget. Payments may be contingent upon certification of the Subrecipient's financial management system in accordance with the standards specified in 24 CFR 84.21. (a) Amount of Payments. It is expressly agreed and understood that the total amount of Home Program Funds to be paid by the City under this Agreement shall not exceed Five Hundred Twenty -One Thousand Five Hundred ($521,500). The amount of Inclusionary Funds to be paid by the City under this Agreement shall not exceed Ninety-one Thousand Dollars Three Hundred and Fifty ($91,350) annually. The dollar amount stated in the immediately preceding sentence may be increased by written amendment of this Agreement, signed by an authorized representative of Subrecipient and the Deputy Director. (b) Requests for Payments. To receive each payment under this Agreement, Subrecipient shall submit to the City a written reimbursement request or invoice in a form approved by City, along with such supporting documentation as may be requested by the City to verify Subrecipient's performance of the Services for which the payment is requested. Reimbursement requests shall be submitted no more frequently than two times per month. Payments will be adjusted by the City in accordance with fund advances, if any, and program income balances available in Subrecipient accounts. In addition, the City reserves the right to liquidate funds available under this Agreement for costs incurred by the City on behalf of the Subrecipient. 3.3 Payments Subject to Availability of HOME Funds. City's obligation to provide payments to Subrecipient hereunder is subject to City's receipt of HOME Funds from HUD pursuant to the HOME Program. 3.4 Accounting. Subrecipient shall, upon request, provide City with an accounting report, in form and content reasonably satisfactory to City, of any funds disbursed by City pursuant to Section 3.2. ARTICLE 4 INSURANCE AND INDEMNIFICATION 4.1 Insurance. Without limiting City's right to indemnification, Subrecipient shall secure prior to commencing the performance of any Services under this Agreement, and maintain during the Term of this Agreement, insurance coverage as set forth in this Section. (a) Required Insurance. Subrecipient shall secure and maintain the following coverage: (1) Workers' Compensation Insurance as required by California statutes; (ii) Comprehensive General Liability Insurance, or Commercial General Liability Insurance, including coverage for Premises and Operations, 18-6744/185593/mv 14 Contractual Liability, Personal Injury Liability, Products/Completed Operations Liability, Broad -Form Property Damage, Independent Contractor's Liability and Fire Damage Legal Liability, in an amount of not less than One Million Dollars ($1,000,000.00) per occurrence, combined single limit, written on an occurrence form; and (iii) Comprehensive Automobile Liability coverage, including — as applicable — owned, non -owned and hired autos, in an amount of not less than One Million Dollars ($1,000,000.00) per occurrence, combined single -limit, written on an occurrence form. The Deputy Director, with the consent of City's Risk Manager is hereby authorized to modify the requirements set forth above in the event he or she determines that a modification, whether an increase or decrease, is in City's best interest. (b) Required Clauses in Policies. Each insurance policy required by this Agreement shall contain the following clauses: "This insurance shall not be canceled or allowed to lapse without at least ten (10) days' prior written notice given to the City Clerk of the City of Huntington Beach, 2000 Main Street, Huntington Beach, CA 92648." "It is agreed that any insurance maintained by the City of Huntington Beach shall apply in excess of and not contribute with insurance provided by this policy." Each insurance policy required by this Agreement, excepting policies for workers' compensation, shall contain the following clause: "The City of Huntington Beach, its officials, agents, employees, representative, and volunteers are added as additional insureds as respects operations and activities of, or on behalf of the named insured, performed under contract with the City of Huntington Beach. Subrecipient hereby agrees to waive subrogation which any insurer of the Subrecipient may acquire from the Subrecipient by virtue of the payment of any loss. If requested by City, Subrecipient agrees to obtain and deliver to City an endorsement from Subrecipient's general liability and automobile insurance insurer to effect this waiver of subrogation. (c) Property Insurance. Subrecipient shall further comply with the insurance requirements of 24 CFR 84.31. (d) Required Certificates and Endorsements. Prior to commencement of any Services under this Agreement, the Subrecipient shall deliver to City (i) insurance certificates confirming the existence of the insurance required by this Agreement, and including the applicable clauses referenced above, and (ii) endorsements to the 18-6744/185593/mv 15 above -required policies, which add to these policies the applicable clauses referenced above. Such endorsements shall be signed by an authorized representative of the insurance company and shall include the signator's company affiliation and title. Should it be deemed necessary by City, it shall be the Subrecipient's responsibility to see that City receives documentation, acceptable to City, which sustains that the individual signing such endorsements is indeed authorized to do so by the insurance company. Also, City reserves the right at any time to demand, and to receive within a reasonable time period, certified copies of any insurance policies required under this Agreement, including endorsements effecting the coverage required by these specifications. (e) Remedies for Defaults Re: Insurance. In addition to any other remedies City may have if the Subrecipient fails to provide or maintain any insurance policies or policy endorsements to the extent and within the time herein required, City may, at its sole option: (i) Obtain such insurance and deduct and retain the amount of the premium for such insurance from any sums due under the Agreement; (ii) Order the Subrecipient to stop work under this Agreement and/or withhold any payment(s) which become due to the Subrecipient hereunder until the Subrecipient demonstrates compliance with the requirements hereof; or (ill) Terminate this Agreement. Exercise of any of the above remedies, however, is an alternative to other remedies City may have and is not the exclusive remedy for the Subrecipient's failure to maintain insurance or secure appropriate endorsements. Nothing herein contained shall be construed as limiting in any way the extent to which the Subrecipient may be held responsible for payment of damages to persons or property resulting from the Subrecipient's or its subcontractor's performance of the Services covered under this Agreement. 4.2 Indemnification. (a) As respects acts, errors or omissions in the performance of Services under this Agreement, the Subrecipient agrees to defend, indemnify and hold harmless City, its officers, agents, employees, representatives and volunteers from and against any and all claims, demands, defense costs, liability or consequential damages of any kind or nature arising directly out of the Subrecipient's negligent acts, errors or omissions in the performance of Services under the terms of this Agreement. (b) As respects all acts or omissions which do not arise directly out of the performance of Services, including but not limited to those acts or omissions normally covered 18-6744/185593/mv 16 by general and automobile liability insurance, Subrecipient agrees to indemnify, and hold harmless City, its officers, agents, employees, representatives, and volunteers from and against any and all claims, demands, defense costs, liability, or consequential damages of any kind or nature arising out of or in connection with Subrecipient's performance or failure to perform, under this Agreement; excepting those which arise out of the sole negligence of City. ARTICLE 5 ADMINISTRATIVE REQUIREMENTS 5.1 Financial Management. (a) Accounting Standards. Subrecipient agrees to comply with 24 CFR 84.21 through 84.28 and agrees to adhere to the accounting principles and procedures required therein, utilize adequate internal controls, and maintain necessary source documentation for all costs incurred. (b) Cost Principles. Subrecipient shall administer its program in conformance with OMB Circulars A-122, "Cost Principles for Non -Profit Organization." These principles shall be applied for all costs incurred whether charged on a direct or indirect basis. 5.2 Documentation, Recordkeeping, Reporting and Monitoring. Subrecipient shall maintain documents and records, prepare and submit reports, and permit City to monitor Subrecipient's activities all in accordance with the requirements set forth in Exhibit B and applicable laws and regulations. All requirements set forth in such Exhibit B are incorporated herein as if set forth in full in this Agreement. 5.3 Use and Reversion of Assets. The use and disposition of property and equipment under this Agreement shall be in compliance with the requirements of 24 CFR Part 84 and 24 CFT 92.504, as applicable. The Subrecipient shall transfer to the City any HOME Funds on hand and any accounts receivable attributable to the use of HOME Funds under this Agreement at the time of the earliest to occur of expiration, cancellation, or termination. 5.4 Ownership of Documents. All documents and materials, both tangible and intangible, furnished by or through the City to Subrecipient pursuant to this Agreement are and shall remain the property of City and shall be returned to City upon the earliest to occur of expiration, cancellation, or termination of this Agreement. All documents and materials prepared by Subrecipient under or related to this Agreement shall become the property of City at the time of payment to Subrecipient of all fees, if any, for their preparation, and shall be delivered to City by Subrecipient at the request of City, and in any event upon the earliest to occur of expiration, cancellation, or termination of this Agreement. 18-6744/185593/mv 17 ARTICLE 6 PERSONNEL & PARTICIPANT CONDITIONS 6.1 Civil Rights. (a) Compliance. The Subrecipient agrees to comply with the Huntington Beach Municipal Code, Government Code Section 4450, et seq., the Unruh Civil Rights Act, Civil Code Section 51, et seq., Title VI of the Civil Rights Act of 1964, as amended, Title VIII of the Civil Rights Act of 1968 as amended, Section 104(b) and Section 109 of Title 1 of the Housing and Community Development Act of 1974, as amended, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990, the Age Discrimination Act of 1975, Executive Order 11063, and Executive Order 11246 as amended by Executive Orders 11375, 11478, 12107 and 12086. (b) Nondiscrimination. The Subrecipient agrees to comply with (1) the requirements of 24 CFR Part 5, subpart A, which relate to nondiscrimination and equal opportunity; (2) the nondiscrimination requirements of Section 282 of the HOME Investment Partnerships Act, 42 U.S.C. Section 12701, et seq. (c) Section 504. The Subrecipient agrees to comply with all federal regulations issued pursuant to compliance with Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), which prohibits discrimination against the individuals with disabilities or handicaps in any federally assisted program. 6.2 Affirmative Action. (a) Executive Order 11246. The Subrecipient agrees that it shall be committed to carry out pursuant to the City's specifications an Affirmative Action Program in keeping with the principles as provided in President's Executive Order 11246 of September 24, 1966. (b) Women- and Minority -Owned Businesses (W/MBE). The Subrecipient will use its best efforts to afford small businesses, minority business enterprises, and women's business enterprises the maximum practicable opportunity to participate in the perfonnance of this Agreement. As used in this Agreement, the terms "small business" means a business that meets the "minority and women's business enterprise" means a business at least fifty-one percent (51 %) owned and controlled by minority group members or women. For the purpose of this definition, "minority group members" are Afro-Americans, Spanish-speaking, Spanish surnamed or Spanish -heritage Americans, Asian -Americans, and American Indians. The Subrecipient may rely on written representations by businesses regarding their status as minority and female business enterprises in lieu of an independent investigation. 18-6744/185593/mv 18 (c) Equal Employment Opportunity and Affirmative Action (EEO/AA) Statement. The Subrecipient will, in all solicitations or advertisements for employees placed by or on behalf of the Subrecipient, state that it is an Equal Opportunity or Affirmative Action employer. (d) Subcontract Provisions. The Subrecipient will include the provisions of Sections 6.1, Civil Rights, and 6.2, Affirmative Action, in every subcontract or purchase order, specifically or by reference, so that such provisions will be binding upon each of its own sub-subrecipients or subcontractors. 6.3 Employment Restrictions. (a) Prohibited Activity. The Subrecipient is prohibited from using HOME Funds provided herein or personnel employed in. the administration of the program for: political activities; inherently religious activities; lobbying; political patronage; and nepotism activities. (b) Labor Standard. The Subrecipient agrees to comply with the requirements of the Secretary of Labor in accordance with the Davis -Bacon Act as amended, the provisions of Contract Work Hours and Safety Standards Act (40 U.S.C. 327 et seq.) and all other applicable federal, state and local laws and regulations pertaining to labor standards insofar as and when those acts apply to the performance of this Agreement. The Subrecipient agrees to comply with the Copeland Anti -Kick Back Act (18 U.S.C. 874 et seq.) and the implementing regulations thereto issued by the U.S. Department of Labor at 29 CFR Part 5. The Subrecipient shall maintain documentation that demonstrates compliance with applicable hour and wage requirements. (c) Prevailing Wage. The Subrecipient agrees that, to the extent applicable, all contractors engaged under contracts for construction, renovation or repair work financed in whole or in part with assistance provided under this Agreement shall comply with the regulations of the Department of Labor, under 29 CFR Parts 1, 3, 5 and 7 and California Labor Code Section 1720, et seq. governing the payment of wages and ratio of apprentices and trainees to journey workers. The Subrecipient shall cause or require to be inserted in full, in all such contracts subject to such regulations, provisions meeting the requirements of this paragraph. (d) Section 3 Clause. The Subrecipient agrees, to the extent applicable, to comply with Section 3 of the HUD Act of 1968, as amended, and as implemented by the regulations set forth in 24 CFR 135. 18-6744/185593/mv 19 6.4 Conduct (a) Assignment. The Subrecipient shall not assign or transfer any interest in this Agreement without the prior written consent of the City thereto; provided, however, that claims for money due or to become due to the Subrecipient from the City under this Agreement may be assigned to a bank, trust company, or other financial institution without such approval. Notice of any such assignment or transfer shall be furnished promptly to the City. (b) Subcontracts. (i) Approvals. The Subrecipient shall not enter into any subcontracts with any entity, agency or individual in the performance of this Agreement without the written consent of the City prior to the execution of such agreement. (ii) Monitoring. The Subrecipient will monitor all subcontracted services on a regular basis to assure contract compliance. Results of monitoring efforts shall be summarized in written reports and supported with documented evidence of follow-up actions taken to correct areas of noncompliance. (iii) Content. The Subrecipient shall cause all of the provisions of this Agreement in its entirety to be included in and made a part of any subcontract executed in the performance of this Agreement. (iv) Selection Process. The Subrecipient shall undertake to insure that all subcontracts let in the performance of this Agreement shall be awarded on a fair and open competition basis in accordance with applicable procurement requirements. Executed copies of all subcontracts shall be forwarded to the City along with documentation concerning the selection process. (c) Hatch Act. The Subrecipient agrees that no funds provided, nor personnel employed under this Agreement, shall be in any way or to any extent engaged in the conduct of political activities in violation of Chapter 15 of Title V of the U.S.C. (d) Conflict of Interest. The Subrecipient agrees to abide by the provisions of 24 CFR 84.42 and 92.356, which include (but are not limited to) the following: (i) The Subrecipient shall maintain a written code or standards of conduct that shall govern the performance of its officers, employees or agents engaged in the award and administration of contracts supported by HOME Funds. (ii) No employee, officer or agent of the Subrecipient shall participate in the selection, or in the award, or administration of, a contract supported by 18-6744/185593/mv 20 HOME Funds if a conflict of interest, real or apparent, would be involved. (iii) No covered persons who exercise or have exercised any functions or responsibilities with respect to HOME -assisted activities, or who are in a position to participate in a decision -making process or gain inside information with regard to such activities, may obtain a financial interest in any contract, or have a financial interest in any contract, subcontract, or agreement with respect to the HOME -assisted activity, or with respect to the proceeds from the HOME -assisted activity, either for themselves or those with whom they have business or immediate family ties, during their tenure or for a period of one (1) year thereafter. For purposes of this paragraph, a "covered person" includes any person who is an employee, agent, consultant, officer, or elected or appointed official of the City, the Subrecipient, or any designated public agency. (e) Lobbying. The Subrecipient hereby certifies that: (i) No federal appropriated funds have been paid or will be paid, by or on behalf of it, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal 1 oan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement; (ii) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, it will complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions; and (iii) It will require that the language of paragraph (iv) of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all Subrecipients shall certify and disclose accordingly. (f) Lobbying Certification. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352 Title 31, US.C. Any person who fails to file 18-6744/185593/mv 21 the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. (g) Religious Activities. The Subrecipient agrees that funds provided under this Agreement will not be utilized for inherently religious activities such as worship, religious instruction, or proselytization. ARTICLE 7 GENERAL CONDITIONS 7.1 General Compliance. The Subrecipient agrees to comply with the requirements of the HOME Program in the administration and implementation of the TBRA Program and this Agreement. The Subrecipient shall carry out each activity in compliance with all regulations described in subpart H of 24 CFR Part 92, except that the Subrecipient does not assume the City's responsibilities for environmental review under 24 CPR 92.352 and the intergovernmental review process described in 24 CFR 92.357 does not apply to the Subrecipient. The Subrecipient also agrees to comply with all other applicable federal, state and local laws, regulations, and policies governing the funds provided under this Agreement. The Subrecipient further agrees to utilize funds available under this Agreement to supplement rather than supplant funds otherwise available. 7.2 Familiarity with Services; Qualified Personnel. (a) By executing this Agreement, Subrecipient represents and warrants that Subrecipient (i) has thoroughly investigated and considered the Services to be performed, (ii) has carefully considered how the Services should be performed, and (iii) fully understands the requirements, difficulties and restrictions attending the performance of the Services under this Agreement. (b) Subrecipient represents that Subrecipient has or will secure and maintain, at Subrecipient's sole cost and expense, all qualified and licensed personnel required to perform the Services. Staff and any additional personnel hired by Subrecipient shall be employees of Subrecipient. Such personnel shall not be deemed to be employees of City or to have any contractual relationship with City. Such Personnel shall be authorized or permitted under state and local law to perform the Services. 7.3 Independent Contractor. In performing under this Agreement, Subrecipient is and shall at all times be acting and perfonning as an independent contractor to City, performing its duties in accordance with its own judgment. City shall neither have nor exercise any control or direction over the methods by which Subrecipient performs its work and function nor shall City have the right to interfere with such freedom or action or prescribe rules or otherwise control or direct the manner in which such services are performed. The sole interest of the City in the Services performed by the Subrecipient is that such Services be performed in a legal competent, efficient and satisfactory manner. Nothing contained herein shall cause the relationship between the parties to this Agreement to be that of 18-6744/185593/mv 22 employer and employee. Subrecipient shall not have the authority to obligate City to any contract, obligation, or undertaking whatsoever and shall make no representation, either oral or in writing. 7.4 Subrecipient Representative. Subrecipient hereby designates Madelynn Himeise as its Project Manager for the TBRA Program ("Subrecipient's Representative"). Subrecipient's Representative shall supervise and direct the Services, using his or her best skill and attention, and shall be responsible for all means, methods, techniques, sequences and procedures and for the satisfactory coordination of all portions of the Services under this Agreement. 7.5 Nepotism. Subrecipient shall not hire or permit the hiring of any person to fill a position funded through this Agreement if a member of the person's immediate family is employed in an administrative capacity by City's HOME Program or any department of the City which is administering the HOME Program. For the purposes of this section, the term "immediate- family' means spouse, child, mother, father brother, sister, brother-in-law, sister-in-law, father-in-law, mother-in-law, son-in-law, daughter-in-law, aunt, uncle, stepparent and stepchild. The term "administrative capacity" means having selection, hiring, supervisory or management responsibilities, including serving on the governing body of City. 7.6 Hold Harmless. The Subrecipient shall indemnify, hold harmless, and defend the City and their elected officials, officers, employees and agents and shall pay for expenses incurred by the City for any and all claims, actions, suits, charges and judgments whatsoever related in any manner to or that arise out of the Subrecipient's performance or nonperformance of the Services or subject matter called for in this Agreement. 7.7 City Recognition. The Subrecipient shall insure recognition of the role of the City in providing Services through this Agreement. All activities, facilities and items utilized pursuant to this Agreement shall be prominently labeled as to funding source. 7.8 Notices. Any approval, disapproval, demand, document or other notice ("Notice") which any party may desire to give to the other party under this Agreement must be in writing and may be given either by (i) personal service, (ii) delivery by reputable document delivery service such as Federal Express that provides a receipt showing date and time of delivery, (ill) facsimile transmission, or (vi) mailing in the United States mail, certified mail, postage prepaid, return receipt requested, addressed to the address of the party as set forth below, or at any other address as that party may later designate by Notice. Service shall be deemed conclusively made at the time of service if personally served; upon confirmation of receipt if sent by facsimile transmission; the next business if sent by overnight courier and receipt is confirmed by the signature of an agent or employee of the party served; the next business day after deposit in the United States mail, properly addressed and postage prepaid, return receipt requested, if served by express mail; and three (3) days after deposit in the United States mail, properly addressed and postage prepaid, return receipt requested, if served by certified mail. 18-6744/185593/mv 23 Subrecipient: Families Forward Madelynn Hirneise 8 Thomas Irvine, CA 92618 City: City Clerk City of Huntington Beach 2000 Main Street Huntington Beach, CA 92648 With copies to: Kellee Fritzal Office of Business Development 2000 Main Street Huntington Beach, CA 92648 Such addresses may be changed by Notice to the other party(ies) given in the same manner as provided above. 7.9 Amendment and Waiver. This Agreement may be amended, modified, or supplemented only by a writing executed by each of the parties. Any party may in writing waive any provision of this Agreement to the extent such provision is for the benefit of the waiving party. No action taken pursuant to this Agreement, including any investigation by or on behalf of any party, shall be deemed to constitute a waiver by that party or its or any other party's compliance with any representations or warranties or with any provision of this Agreement. 7.10 Entire Agreement. This Agreement, including all Exhibits attached hereto, embodies the entire agreement and understanding between the parties pertaining to the subject matter of this Agreement and supersedes all prior agreements, understandings, negotiations, representations, and discussions, whether verbal or written, of the parties pertaining to the subject matter. In the event of a conflict between this Agreement, on one hand, and any Exhibit attached hereto, on the other hand, the provisions of this Agreement shall control; provided, if it is possible to comply with the requirements of this Agreement and the Exhibits, the parties shall do so. The following Exhibits are attached to this Agreement and incorporated herein: Exhibit A TBRA Program Operating Guidelines Appendix A Initial Qualification Form Appendix B TBRA Application Appendix C Declaration of Homelessness Appendix D Housing Quality Standards (HQS) Inspection Checklist 18-6744/ 185 593/mv 24 Appendix E Landlord Agreement Appendix F Lease Addendum Appendix G Rent Reasonableness Standard Appendix H Orange County Housing Authority — Utility Allowance Schedule Appendix I Participant Agreement Appendix J Case Management and Self Sufficiency Program Policies and Procedures Exhibit B Documentation, Recordkeeping, Reporting and Monitoring Requirements Exhibit C Gross Income Calculation Form Exhibit D Housing Budget Worksheet Exhibit E Lead -Based Hazard Information Pamphlet "Protect Your Family from Lead in your Home'' Exhibit F Budget 7.11 Governing Law. The validity, construction, and performance of this Agreement shall be governed by the laws of the State of California. 7.12 Non -Liability of Members, Officials and Employees of City. No member, official or employee of City shall be personally liable to Subrecipient, or any successor in interest, in the event of any Default or breach by City or for any amount which may become due to Subrecipient or Subrecipient's successors, or on any obligation under the terms of this Agreement. Subrecipient hereby waives and releases any claim Subrecipient may have against the member, officials or employees of City with respect to any Default or breach by City or for any amount which may become due to Subrecipient or Subrecipient's successors, or any obligations under the terms of this Agreement. Subrecipient makes such release with the full knowledge of Civil Code Section 1542 and hereby waives any and all rights thereunder to the extent of this release, if such Section 1542 is applicable. Section 1542 of the Civil Code provides as follows: "A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING 18-6744/185593/mv 25 THE RELEASE, WHICH IF KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR." ARTICLE 8 ENFORCEMENT; TERMINATION 8.1 Events of Default. (a) For purposes of this Agreement, the word "Default" shall mean the failure of Subrecipient to perform any of Subrecipient's duties or obligations or the breach by Subrecipient of any of the terms and conditions set forth in this Agreement; any failure by Subrecipient to comply with any of the rules, regulations or provisions referred to herein, or such statutes, regulations, executive orders, and HUD guidelines, policies or directives as may become applicable at any time; any ineffective or improper use of funds provided under this Agreement; or submission by the Subrecipient to the City reports that are incorrect or incomplete in any material respect. In addition, Subrecipient shall be deemed to be in Default upon Subrecipient's (i) application for, consent to, or suffering of, the appointment of a receiver, trustee or liquidator for all or a substantial portion of its assets, (ii) making a general assignment for the benefit of creditors, (ill) being adjudged bankrupt, filing a voluntary petition or suffering an involuntary petition under any bankruptcy, arrangement, reorganization or insolvency law (unless in the case of an involuntary petition, the same is dismissed within thirty (30) days of such filing), or (v) suffering or permitting to continue unstayed and in effect for fifteen (15) consecutive days any attachment, levy, execution or seizure of all or a substantial portion of Subrecipient's assets or of Subrecipient' s interests hereunder. (b) City shall not be deemed to be in Default in the performance of any obligation required to he performed by City hereunder unless and until City has failed to perform such obligation for a period of thirty (30) days after receipt of written notice from Subrecipient specifying in reasonable detail the nature and extent of any such failure; provided, however, that if the nature of City's obligation is such that more than thirty (30) days are required for its performance, then City shall not be deemed to be in Default if City shall commence to cure such performance within such thirty (30) day period and thereafter diligently prosecute the same to completion. 8.2 Institution of Legal Actions. In addition to any other rights and remedies, and subject to the restrictions otherwise set forth in this Agreement, either party may institute an action at law or in equity to seek the specific performance of the terms of this Agreement, to cure, correct or remedy any Default, to recover damages for any Default or to obtain any other remedy consistent with the purpose of this Agreement. Such legal actions must be instituted in the Superior Court of the County of California, State of 18-6744/ 185593/mv 26 California or in the United States District Court for the Central District of California. 8.3 Acceptance of Service of Process. In the event that any legal action is commenced by the Subrecipient against City, service of process on City shall be made by personal service upon the City Clerk or in such other manner as may be provided by law. In the event that any legal action is commenced by City against the Subrecipient, service of process on the Subrecipient shall be made by personal service upon Subrecipient's Representative or in such other manner as may be provided by law. 8.4 Rights and Remedies Are Cumulative. Except as otherwise expressly stated in this Agreement, the rights and remedies of the parties are cumulative, and the exercise by either party of one or more of such rights or remedies shall not preclude the exercise by it, at the same or different times, of any other rights or remedies for the same Default or any other Default by the other party. 8.5 Inaction Not a Waiver of Default. Any failures or delays by either party in asserting any of its rights and remedies as to any Default shall not operate as a waiver of any Default or of any such rights or remedies, or deprive either such party of its right to institute and maintain any actions or proceedings which it may deem necessary to protect, assert or enforce any such rights or remedies. 8.6 Attorney's Fees. City and Subrecipient agree that in the event of litigation to enforce this Agreement or terms, provisions and conditions contained herein, to terminate this Agreement, or to collect damages for a Default hereunder, the prevailing party shall not be entitled to costs and expenses, including reasonable attorney's fees, incurred in connection with such litigation, such that each party shall be responsible for their costs and attorneys' fees. 8.7 Termination. (a) Termination for Cause. In accordance with 24 CFR 85.43, the City may suspend or terminate this Agreement in the event of a Default by the Subrecipient under this Agreement. Subrecipient may suspend or terminate this Agreement if City fails to make payments to Subrecipient as required herein. (b) Termination for Convenience. In accordance with 24 CFR 85.44, this Agreement may also be terminated for convenience by either the City or the Subrecipient, in whole or in part, by setting forth the reasons for such termination, the date the termination will be effective, and, in the case of partial termination, the portion to be terminated. However, if in the case of a partial termination, the City determines that the remaining portion of the award will not accomplish the purpose for which the award was made, the City may terminate the award in its entirety. 18-6744/185593/mv 27 IN WITNESS WHEREOF, the parties have executed this HOME Recipient Agreement (Tenant Based Rental Assistance) as of the Effective Date, which is the date of the City Council approving this Agreement. SUBRECIPIENT: FAMILIES FORWARD a California nonprofit corporation ' --4c /, I ITS: (circle AND �5O By: print name ITS: (circle one) rrrPt e!/ L :oFr a nF�rrr/�SSt. COUNTERPART CITY: CITY OF HUNTINGTON BEACH, a municipal corporation and charter city Mayor ATTEST: City Clerk APPROVED AS TO FORM: By: City Attorney r W INITIATED AND APPROVED: By: Deputy Director of Business Development REVIEWED AND APPROVED: City Manager 18-6744/185593/mv 28 IN WITNESS WHEREOF, the parties have executed this HOME Recipient Agreement (Tenant Based Rental Assistance) as of the Effective Date, which is the date of the City Council approving this Agreement. SUBRECIPIENT: FAMILIES FORWARD a California nonprofit corporation Print name ITS: (circle one) Chairman/PresidenlNice President M. print name ITS: (circle one) Secretary/Chief Financial Officer/Asst. Secretary — Treasurer COUNTERPART CITY: CITY OF HUNTINGTON BEACH, a municipal corporation and charter city Mayor ATTEST: Q 7� City , lerk /0104//8j?6 APPROVED AS T By: City Oorney A,u✓ INITIfATED AND APPROVED: y: Deputy Di r o Business Development APPROVED- 18-6744/185593/mv 28 Families Forward Exhibit A Operating Guidelines City of HuntintZton Beach Tenant -Based Rental Assistance Program Operating Guidelines L Program Overview The City of Huntington Beach (City) has established a Tenant -Based Rental Assistance (TBRA) Program to assist families with at least one child under the age of 19 from the City to transition into permanent, supportive housing. The City wishes to have fifty percent (50%) of new clients referred by the Huntington Beach Task Force. Families who are literally homeless will be referred into the TBRA through Orange County's Coordinated Entry System (OC CES). The City is currently implementing a coordinated one-year strategy and program to provide financial assistance to eligible extremely low, very low and lower income families and households to enable such households to secure housing available at an affordable housing cost in the City. The program will be utilizing HOME Funds to provide tenant -based rental assistance, security deposit assistance and utility assistance for families consisting of at least one child under the age of 19 experiencing homelessness or at risk of homelessness who are residents of the City. II. Marketing and Outreach and Application Process A. Marketing and Outreach Families Forward is responsible for the marketing and outreach activities to find prospective eligible households interested in the TBRA Program. Families Forward will conduct regular outreach activities with the Huntington Beach Task Force and access Orange County's Coordinated Entry System's Prioritization List (PL) for literally homeless families coming from the City. All activities will be performed in accordance with HUD's Affirmative Fair Housing and Marketing regulations and the City's Affirmative Fair Housing Marketing plan. B. Waiting List Families Forward will obtain eligible families through Orange County's Coordinated Entry System's PL. If there are more eligible families than program slots available in the TBRA program, then Families Forward will work within the Coordinated Entry System to connect eligible households to appropriate services within Orange County. C. Intake Process Prospective eligible households are literally homeless families consisting of at least one parent and one child under the age of 19. Eligible households who are referred from the Huntington Beach Task Force and have not completed a Vulnerability Index- Service Prioritization Decision Assistance Tool (VI-SPDAT), will be referred to an appropriate access point within the OC CES to complete the assessment. The VI-SPDAT tool is utilized by the entire OC Continuum of Care to prioritize homeless persons seeking help. The score calculated from the VI-SPDAT helps to ensure that the most vulnerable persons are receiving immediate service without bias. Score ranges and housing intervention: - 0-3 No Housing Intervention - 4-8 Rapid Re -Housing - 9+ Permanent Supportive Housing (chronically homeless and disabled) or Orange County Housing Authority Voucher Program (NOT chronically homeless and/or disabled) Fifty percent (50%) of new clients will be referred by the Huntington Beach Homeless Task Force that present a tie to the City. Families Forward will also obtain up to 50% of eligible households through Families Forward participation in the Orange County's Coordinated Entry System's PL process. A housing opportunity, with a City of Huntington Beach preference, will be presented at the weekly case conferencing meeting for a match back to Families Forward. Once a match has been made with a homeless Huntington Beach family, Families Forward will complete an initial triage form, following the protocol of the OC CES. Families Forward will schedule an appointment with each eligible household and provide the following forms for completion: - Homelessness Certification o Client will sign Homelessness Certification and provide approved homeless status documentation from either an agency, emergency shelter, church or social service agency o If client states the family is sleeping in their car, Families Forward will complete a car inspection in the Families Forward parking lot. Families Forward will sign Homelessness Certification verifying homelessness. D. Guidance for Eligible Households Families Forward will meet with prospective eligible households throughout the application process and shall continue to meet with and counsel each eligible household regarding the TBRA Program, the eligible household's responsibilities as participants of the TBRA Program, and the goals and objectives of the TBRA Program. III. Determination of Eligibility Families Forward will qualify all eligible households in accordance with the HOME program, the City's Consolidated Plan and the City's housing needs and priorities. Eligibility for program services shall adhere to the following criteria: - Eligible low-income households total monthly income must be no more than 80% AMI, currently residents of the City of Huntington Beach, currently homeless or at risk of homelessness and include at least one child (under the age of 19). - For determining eligibility for the TBRA Program, a prospective eligible household's (or for continuing compliance, a participating eligible household's) gross annual income shall be determined in accordance with 24 CFR 5.609, with the allowable exclusions from income established at 24 CFR 5.611. A. Income Eligible Households - Annual income will be the gross amount of income from all sources, including assets, for all adult household members that is anticipated to be received prospectively during the 12-month period following the date of application and before any deductions are taken (and for a participating household, income anticipated for the 12 months following re -verification.) - When collecting income verification documentation, Families Forward may also consider any likely changes in income. - For purposes of the TBRA Program, income limits for extremely -low, very -low and low-income households are established annually by HUD for the Orange County income limit area. - Initial income verification for eligible households will be verified for each applicant's household income using source documentation such as wage statements, interest statements, unemployment compensation statements, bank account statements, and other documentation types approved by HUD. Once an initial income verification is completed, Families Forward is not required to re- examine the eligible household's income unless six months has elapsed before assistance is provided. - Families Forward will perform an annual recertification for income and re -qualify each eligible household. B. Verification of Eligibility Families Forward will collect and examine documentation submitted by the Eligible Household to verify the identity of the members of the Eligible Household and that the Eligible Household includes at least one child (under 19 years old). Families Forward will abide by HUD's definition of Category I literally homeless for all Eligible Households. Literally Homeless Definition- An individual or family who lacks a fixed, regular, and adequate nighttime residence, which includes a primary nighttime residence of: - Place not designed for or ordinarily used as a regular sleeping accommodation (including a car, park, abandoned building, bus/train station, airport, or camping ground) - A supervised publicly or privately -operated shelter designated to provide temporary living arrangements (including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state, or local government programs) - Or an individual is considered homeless if she or he is being discharged from an institution where she or she has been a resident for 90 days or less and the person resided in a shelter (not transitional housing) or place not meant for human habitation immediately prior to entering that institution Eligible Households will be required to complete the Homelessness Certification and provide supporting homeless documentation from agency, emergency shelter, church or social service agency. If client is stating the family is sleeping in their car, Families Forward will complete a car inspection in the Families Forward parking lot. Families Forward will sign Homelessness Certification verifying homelessness Families Forward will verify resident ties to the City. Examples of acceptable documentation to confirm recent residency include: - Copy of previous lease - Copy of previous utility bill - Written confirmation of residency from a previous landlord, or proof of residency in transitional living facility - Copy of school records confirming previous residency Examples of proof of strong ties to the community include: - Current residency of an immediate family member — mother, father, sibling, child, or grandparent - Proof that the individual and/or their dependent(s) attended K-12 school in Huntington Beach - Written acknowledgement from the Huntington Beach Police Department or Homeless Task Force that individual has been living in Huntington Beach's streets for 18 months. Special Circumstances — the following categories of individuals may meet the definition of Huntington Beach Homeless Resident: - Homeless individuals that are "Medically Compromised" - Elderly homeless individuals (60+) - If the Huntington Beach Police Department (HBPD or Homeless Task Force (HTF) staff believe that an individual's well-being will be severely compromised by living on the street and/or if the individual is a chronic nuisance or offender who's presence in Huntington Beach poses a threat to others or in a consistent drain on public resources, then a team composted of HBPD/HTF may, on a case -by -case basis, determine that such individual qualifies as a HB Homeless Resident. C. Eligible Households At -Risk of Homelessness A prospective Eligible Household who is at -risk of homelessness shall meet with Families Forward to determine and verify their qualifications and eligibility for rental, utility or security deposit funding assistance. An income calculation based on three months of source documentation (bank account statements, pay stubs, etc.) to prequalify such prospective Eligible Household will be conducted. Eligible households receiving assistance will be required to provide: (i) Completed Communication Disclosure and Consent to Exchange Information Form (ii) Completed Registration Form (iii) State -issued identification for each adult in household (iv) Birth certificate, school 1D, last report card, immunization record OR Social Security card for each child in household (v) Copy of the lease (vi) Copy of landlord's W-9 form. Families Forward will communicate with the landlord to mediate eviction prevention and provide negotiated financial assistance directly to the landlord to halt the eviction process. The assistance will be a one-time issuance and must result in halting the current eviction process. Income documentation must verify the family's ability to maintain rental payments going forward. D. Written Notice of Eligibility Families Forward will provide written notice of eligibility to each applicant stating whether Eligible Household was determined to be eligible for assistance under the TBRA Program. Applicants determined to be ineligible for TBRA Program assistance shall have an opportunity to appeal the determination to Families Forward's Executive Director. IV. Selection of Housing A. Housing Unit Selection Eligible Households must be residents of Huntington Beach and may elect to rent any housing unit in Huntington Beach, so long as the unit meets Families Forward's Housing Quality Standards (HQS) or such other standards as may be made applicable to the Program by HOME program statues or regulations. Housing units must also meet federal Rent Reasonableness requirements. Due to the nature of the population served by the program it is expected that Families Forward's Housing Resource Specialist (HRS) will assist eligible households with finding and selecting an appropriate housing unit that meets all program requirements. If an appropriate housing unit cannot be located within the city boundaries, a housing unit can be located outside the city boundaries when housing is not suitable within city boundaries. While Families Forward can refer eligible household to appropriate housing units, households may not be required to select a particular housing unit. Rental assistance under the program is only provided for housing units that meet the criteria established by the City of Huntington Beach HOME/TBRA Program. B. Occupancy Standards The number of persons in each eligible household will determine the required unit type. Each household must comply with the two per bedroom plus one occupancy standard. The following table provides the occupancy standards by unit type. WE One -bedroom Unit Up to 3 Persons Two -bedroom Unit Up to 5 Persons Three -bedroom Unit Up to 7 Persons Four -bedroom Unit Up to 9 Persons C. Property Inspections Prior to occupancy of any housing unit by an eligible household, Families Forward will conduct an HQS assessment to ensure that the unit complies with HQS as set forth in the HOME Program. as well all applicable state and local codes and ordinances, including zoning ordinances. Each HQS inspection with include the following: • Minimum Standards for Permanent Housing • Certification Statement • Rent Reasonableness Checklist and Certification The HQS inspection form is located in Appendix D D. Rent Reasonableness Rental assistance paid on behalf of the Eligible Household must be in compliance with federal rent reasonableness requirements which require that rents paid by or on behalf of assisted households be similar to rents paid by non -assisted households. Rent reasonableness reviews will be performed by Families Forward Housing Resource Specialist. The factors listed below shall be considered when determining rent comparability: • Location and age of unit • Unit size including the number of rooms and square footage of unit • Type of unit construction (e.g., single family, duplex, apartment) • The quality of the unit, which includes the building construction, maintenance and improvements and • Amenities, services and utilities included in rent Under no circumstances shall Families Forward or the assisted household agree to pay more than approved through the rent reasonableness review. Additionally, the assisted household is not allowed to make up any difference in the rent offer. E. Coordination with Landlords Families Forward will meet with and provide guidance to landlords participating in the Program regarding the requirement and procedures that impact landlords. i. Landlord Agreement (Appendix E) Families Forward will enter into a Landlord Agreement with each participating landlord or property owner. The Landlord Agreement will establish the security deposit assistance payment and the initial rental assistance payments to be paid on behalf on the household. The Agreement will also establish the participating household's initial share of the contract rent. The Agreement will also require the landlord to provide Families Forward with notice of a lease termination and reaffirm the tenant protections included in the Tenant Agreement. This contract will have an initial term of 3-12 months, subject to extensions approved by Families Forward and City. ii. Tenant Agreement (Appendix F) • The landlord will be required to enter into a lease agreement with a term of 12 months with any Eligible Household occupying a housing unit. • The lease agreement will include the Tenant Agreement that will be executed in connection with the lease between the landlord and the eligible household. • The Tenant Agreement underlines that any provision of the Lease which falls within the classification below shall not apply and not be enforced by the landlord: o Confession of Judgement o Excusing the Landlord from Responsibility o Waiver of Legal Notice o Wavier of Court Proceedings for Eviction o Waiver of Jury Trial o Waiver of Right to Appeal Court Decision o Tenant Chargeable with Cost of Legal Action Regardless of Outcome of Lawsuit Families Forward will review the lease agreement to confirm its compliance with state law and all HOME program requirements. iii. Participant Agreement (Appendix I) Families Forward will enter into a Participant Agreement with each participating client household. The Participant Agreement will establish the Eligible Household's responsibilities towards rent payments. The Agreement will establish the participating household's initial share of the contract rent. • Term Families Forward will provide rental assistance for a term of 3-12 months, which can be extended in 3-6 month intervals, up to a total of eight times for a cumulative term of up to 24 months. Extensions will be granted at the discretion of the Families Forward and shall be based on continued program compliance and ongoing demonstration of need. V. Payment Standards, Rent Calculation, Term and Subsidy Reductions As authorized by HOME TBRA regulations, the Program will rely on a traditional rental assistance calculation. The model allows for the rent subsidy determination based on 30% household income. A. Rent Assistance Calculation Families Forward shall calculate the "Rental Assistance" payments to be paid on behalf of Eligible Households under this agreement. The initial household rent is equivalent to the maximum subsidy amount allowed under the HOME regulations and is calculated as the difference between 30% of the Eligible Household's gross monthly income and the payment standard. B. Utility Allowance When utilities are included in the cost of renting the unit, that is, the owner assumes responsibility for payment for all utility services, the Eligible Households entire share of the housing costs will go directly to the owner. When the cost of utilities is not part of the rent, that is the Eligible Household is directly responsible for payment of utility services. Families Forward may provide utility deposit assistance on behalf of Eligible Household in the full amount of any utility deposit required for electricity, gas, and/or water services to the utility provider. Utility deposit refunds shall be returned directly to the Eligible Household. C. Security Deposits As needed, Families Forward may provide security deposit assistance to each Eligible Household. The lease must state that security deposit is refundable in accordance with state law. Security deposits may not exceed the value of two month's rent. Families Forward Exhibit A — Appendix A Initial Qualification Form Family Solutions Collaborative Initial Triage Form Interview: Over the phone ❑ In Person ❑ Date: Referred by: Completed by: Agency: 1. Services Requested: I Basic Needs ❑ Case Management ❑ Counseling ❑ Housing ❑ Life Skills ❑ Medical ❑ Workforce/Job training ❑ Other (please specify) 2. General Information: (I will ask you some questions to collect some basic information as the first step of the process) Last Disability, Veteran Race Ethnicity", Adult's Full Name DOB Gender Relation 4 'Status;;i;,- Status to HOH SSN ".(Y/N)>a.�a (Y/N) See below* Hispanic Noah =; ,,,I! ,Hispanic (Head of Household) (Other Adult) (Other Adult) "Native Hawaiian or other Pacific Islander, Black or African American, White, American Indian or Alaska Native, Asian, Ulent refused, client doesn't know. Primary Phone #: Alternate #: Email: Last Permanent address: Zip Code: Primary Language: OC Resident? Y N How Long in have you been in OC? What city do you currently reside in? 3. Do you require immediate medical attention? 4. Do you feel safe where you sleep? ❑Y ❑Y ❑N ❑N 5. Is anyone in the family currently pregnant? 6. Do you have access to food? ❑ Y How far along? ❑ Y ❑N ❑N 7. At Risk - Diversion Intervention Rental............................................................ Monthly Rent? Eviction notice? Date Received: 3-day notice to pay or quit? Date Received: Living with family/friends ............................... Other()...................................... How long can you stay in your current living situation? 1-7 Days r--� � 8-14 days EJ 15+ Days What Resources do you need to stay there longer? What is the reason you cannot stay in your current housing situation longer? 8. Where Did You Sleep Last Night? Car/Street/Park............................................. Shelter........................................................... Which Shelter? Exit date Transitional Housing ....................................... Motel(name) .................................................. Who is currently paying for your motel stay? Circle one: Self/Social Services/Agency/Other Garage/Shed.................................................. Other().... ............ I.—................ 9. What caused your current situation? 10. How much time have you spent in your current situation? 11. Where will you stay tonight? 12. Do you currently have a voucher or subsidy to help you pay rent each month (either current or new)? ❑ Yes (Please specify: ) When does it expire? No 13. Children School District Full % of custody Child's Full Name _ DOB Gender �, or Childcare Program . �- Custody? YorN YorN YorN YorN YorN 14. Employment Employed? Length of>."=" Time Position Title/City , ��,. Monthly ;Income How many hours a week? Applicant Y or N $ Other Adult Y or N $ Other Adult Y or N $ 15. Other Income CaIWORKs/Cash aid: $ Cal Fresh: $ Child/Spousal Support: $ Disability/SSI: $ Other Income (Specify): $ Unemployment: $ 16. Do you have any pets? Y N What kind? How many? Registered as a Service Animal (trained to assist)? 17. Do you have a vehicle? Y N 18. To best assist you, your information may need to be shared with other agencies within the Family Solutions Collaborative. Do you give us permission to share your information to assist in securing resources? Y N To be completed by Agency/ Family Service Navigator: Resources Provided: We appreciate you taking the time to complete the Triage Form. This information will be passed to the Family Service Navigator, from the Family Solutions Collaborative, who will be calling you back within the next 1 to 2 business days. Families Forward Exhibit A — Appendix B TBRA Application OC HMIS: PROJECT INTAKE FORM — CoC/ESG CLIENTPROFILE SOCIAL SECURITY NUMBER (SSN) ==' QUALITY OF SSN ❑ Full SSN reported u Approximate or partial SSN reported ❑Client doesn't know ❑Client refused ❑Data not collected CLIENT'S NAME NIA Last First Middle ❑ Suffix ❑ QUALITY OF NAME ❑ Full name reported n Partial, street name, or.code name reported ❑ Client doesn't know ❑ Client refused ❑ Data not collected DATE OF BIRTH _ I I I — I I I I I Age: Month Day Year QUALITY OF SSN ❑ Full DOB reported i Approximate or partial DOB reported FEIlient doesn't know ❑ Client refused ❑ Data not collected ❑ Female ❑ Trans Female (MTF or Male to Female) ❑ Client doesn't know GENDER ❑ Male [IClient refused ❑ Trans Male (FTM or Female to Male) ❑ Data not collected ❑ White ❑ American Indian or Alaska Native ❑ Client doesn't know RACE ❑ Black or African American ❑ Native Hawaiian or Other Pacific Islander ❑ Client refused ❑ Asian ❑ Data not collected ❑ Non -Hispanic ❑ Client doesn't know ETHNICITY ❑Hispanic ElClient refused ❑ Data not collected ❑ No ❑ Client doesn't know VETERAN STATUS ❑ Li Client refused Yes ❑ Data not collected RELATIONSHIP TO HEAD OF HOUSEHOLD ❑ Self (head of household) ❑ Head of household's other relation member Li Head of household's child Li Other: non relation member LiHead of household's spouse or partner I ACT VNOWN PPPMANFNT Annpp-qC What is the address of the place you last lived for 90 days or more? (Not including emergency shelters or transitional housing) Address County Unit Type Unit Number ZIP Code City State 1 Revised 4/23/18 OC HMIS: PROJECT INTAKE FORM — CoC/ESG IMMUNE1,14 PROJECT NAME PROJECT START DATE — — HOUSING MOVE -IN DATE (For PSH, PH with no disability requirement, and RRH — Projects; Record the date a client or household moves in to a permanent housing unit) LIVING SITUATION for project types rt erthan Street Outreach, Emergency Shelter, or Safe Haven T q., f; Residence 3.917E (Type of living arrangement on,the.ni ht b;efore the, entry into the project HOMELESS SITUATION ❑ Place not meant for human habitation ❑ Safe Haven i Emergency shelter, including hotel or motel paid for with ❑ Interim Housing emergency shelter voucher INSTITUTIONAL SITUATION ❑ Foster care home or foster care group home ❑i Long-term care facility or nursing home ❑ Hospital or other residential non -psychiatric medical facility ❑ Psychiatric hospital or other psychiatric facility ❑ Jail, prison or juvenile detention facility ❑ Substance abuse treatment facility or detox center TRANSITIONAL AND PERMANENT HOUSING SITUATION -- Hotel or motel paid for without emergency shelter voucher ❑ Rental by client, with other housing subsidy (including RRH) u Owned by client, no ongoing housing subsidy ❑ Residential project or halfway house with no homeless criteria ❑ Owned by client, with ongoing housing subsidy ❑ Staying or living in a family member's room, apartment, or Permanent housing (other than RRH) for formerly homeless house persons ❑ Staying or living in a friend's room, apartment or house ❑ Rental by client, no ongoing housing subsidy ❑ Transitional housing for homeless persons ❑ Rental by client, with VASH housing subsidy ❑ Client doesn't know ❑ Rental by client, with GPD TIP subsidy ❑ Client refused ❑ Data not collected Length .&,Sta.in'Prior Living;. it6ation; Duration of PriorLivin Situation ❑ One night or less ❑ One month or more, but less than 90 days ❑ Client doesn't know ❑ Two to six nights ❑ 90 days or more, but less than one year ❑ Client refused ❑ One week or more, but less than one month ❑ One year or longer ❑ Data not collected If Client's Type of Residence is any of the Nameless Situation options: A e6Arnate�Date Homelessness Started Ap` roximate date the client's�;46meless situation began) A, Number:oft mes the client has been>on they treefs; in�ES; orSave Heaven mtl'e past threezyears including,today t Re ardless ofwhereahe sta ed last;ni fit u One time ❑ Three times ❑ Client doesn't know ❑ Two times ❑ Four or more times ❑ Client refused ❑ Data not collected Total number of months homeless on the streets, in ES, or SH in the past three years ❑ One month (this time is the first month) ❑ Six Months ❑ Eleven Months ❑ Two Months ❑ Seven Months ❑ Twelve Months ❑ Three Months ❑ Eight Months ❑ More than 12 months ❑ Four Months ❑ Nine Months ❑ Client doesn't know ❑ Five Months ❑ Ten Months ❑ Client refused ❑ Data not collected Revised 4/23/18 OC HMIS: PROJECT INTAKE FORM — CoC1ESG If Ciienfs Type of Residence is any of the Institutional Situation options: Length of Stay Less,than g0 days? ajr,,p ;:, ®..... :..........:<:% :, .,........ ,....<:....... , .. (Indicate: if `the slay>rtfi'e,;institufional sefting,they lived in°immediately prior to project entry was ❑ No ❑ Yes If Client's Type of Residence is any of the Transitional and Permanent Housing Situation options: Length of Stay Less than 7 nights? (indicate if the stay in the transitionah or permanent housing seftmg they lived m immediately prior ' ❑ No ❑ Yes to project entry was less than 7 nights)._,,,,,,, If 'Length of Stay Less than 90 days' is YES —OR— If 'Length of Stay Less than 7 nights' is YES 06 the night before — xstayed on streets, ES or Safe Heaven? (On the night before &i ,,clients fayof less than,9Q,days in an instit�ional setting, o l6ss`than 7 ",- No ❑ Yes -.9..�, nights in a transitional/perrmanent housing settii g, Nwere they on the streets, in an Emergency ❑ Sheffer, or in a Safe Haven?)_ J�y If 'On the night before — stayed on streets, ES, or Safe Heaven' is YES Ap rozimate Date Homelessness Started a ozimate date the homeless situation began) r« Number of times the client has been"" ^he,,str•eets, ES, or Save Heaven in the three including today :.., . In past Re ardless of where the stayed last 11" ` years ❑ One time ❑ Three times ❑ Client doesn't know ❑ Two times ❑ Four or more times ❑ Client refused ❑ Data not collected Total number of months homeless.on.thest�eefs, i ES or SH in the past three years . ❑ One month (this time is the first month) ❑ Six Months ❑ Eleven Months ❑ Two Months ❑ Seven Months F ❑ Twelve Months ❑ Three Months ❑ Eight Months ❑ More than 12 months ri Four Months ❑ Nine Months ❑ Client doesn't know ❑ Five Months ❑ Ten Months ❑ Client refused ❑ Data not collected Do you have a disabling condition? ❑ No ❑ Client doesn't know ❑ Client refused ❑ Yes ❑ Data not collected Do you have a physical disability? ❑ No ❑ Client doesn't know ❑ Client refused ❑ Yes ❑ Data not collected If yes for Physical Disability, ;; ;a�,F: `� """" n No ❑ Client doesn't know Expected to be of long -continued and indefinite duration and ; ❑ Client refused substantially impairs ability to live independently? in Yes ❑ Data not collected Revised 4/23/18 OC HMIS: PROJECT INTAKE FORM — CoC/ESG Do you have a developmental disability? ❑ No ❑ Client doesn't know ❑ Client refused ❑ Yes ❑ Data not collected If yes for Developmental Disability, L, No ❑ Client doesn't know Expected to be of long -continued and indefinite duration ❑ Client refused and substantially impairs ability to live independently? ❑ Yes ❑ Data not collected Do you have a chronic health condition? ❑ No ❑ Client doesn't know ❑ Client refused ❑ Yes ❑ Data not collected If yes for Chronic Health Condition, ❑ No ❑ Client doesn't know Expected to be of long -continued and indefinite duration and ❑ Client refused substantially impairs ability to live independently? ❑ Yes ❑ Data not collected Have you been diagnosed with AIDS or have you tested positive for HIV? o No ❑ Client doesn't know ❑ Client refused ❑ Yes ❑ Data not collected If yes for tested positive for HIV/AIDS, ❑ No ❑ Client doesn't know Expected to be of long -continued and indefinite duration and ❑ Client refused substantially impairs ability to live independently? ❑ Yes ❑ Data not collected Do you have a mental health problem? ❑ No ❑ Client doesn't know ❑ Client refused ❑ Yes ❑ Data not collected If yes for Mental Health Problem, ❑ No ❑ Client doesn't know Expected to be of long -continued and indefinite duration and ❑ Client refused substantially impairs ability to live independently? ❑ Yes ❑ Data not collected Do you have a substance abuse problem? ❑ No ❑ Client doesn't know ❑ Alcohol Abuse ❑ Client refused Drug Abuse ❑ Data not collected Both Alcohol and Drug If you have any Substance Abuse Problem, ❑ No ❑ Client doesn't know Expected to be of long -continued and indefinite duration and ❑ Client refused substantially impairs ability to live independently? ❑ Yes ❑ Data not collected Are you a survivor of domestic or intimate partner violence? 17 No ❑ Client doesn't know ❑ Client refused n Yes ❑ Data not collected If Yes for survivor of domestic or intimate partner violence When did this experience ❑ Within the past three months ❑ Client doesn't know occur? ❑ Three to six months ago (excluding six months exactly) ❑ Client refused ❑ From six to twelve months ago (excluding one year exactly) ❑Data not collected ❑ More than a year ago ❑ No ❑ Client doesn't know Are you currently fleeing? _, Yes ❑ Client refused ❑ Data not collected 4 Revised 4/23/18 OC HMIS: PROJECT INTAKE FORM — CoCIESG Income from Any Source ❑ No ❑ Yes ❑ Client doesn't know ❑ Client refused ❑ Data not collected IF "YES" TO INCOME FROM ANY SOURCE — INDICATE ALL SOURCES THAT APPLY Income Source Check all that apply) Monthly Amount ❑ Earned Income ❑ Unemployment Insurance ❑ Worker's Compensation ❑ Private Disability Insurance ❑ VA Service -Connected Disability Compensation ❑ Social Security Disability Income SSDI ❑ Supplemental Security Income SSI ❑ Retirement Income from Social Security ❑ VA Non -Service -Connected Disability Pension ❑ Pension or retirement income from a former job ❑ Temporary Assistance for Needy Families TANF ❑ General Assistance GA ❑ Alimony or other spousal support ❑ Child Support ❑ Other Cash Income (Specify: r Receiving Non -Cash Benefits? ❑ No ❑ Client doesn't know ❑ Client refused ❑ Yes ❑ Data not collected IF "YES" TO RECEIVING NON -CASH BENEFITS— INDICATE ALL SOURCES THAT APPLY ❑ Supplemental Nutrition Assistance Program SNAP ❑ TAN Transportation Services ❑ Special Supplemental Nutrition Program for Women, ❑ Other TANF-funded services Infants, and Children WIC ❑ Other Non -Cash Benefits ❑ TANF Childcare Services (Specify Source): MOUSTOW1111111.7-ITMI ❑ No ❑ Client doesn't know Covered by Health Insurance? ❑ Client refused ❑ Yes ❑ Data not collected IF "YES" TO COVERED BY HEALTH INSURANCE— INDICATE ALL SOURCES THAT APPLY ` ❑ MEDICAID ❑ Insurance Obtained through COBRA ❑ MEDICARE ❑ Private Pay Health Insurance ❑ State Children's Health Insurance Program ❑ State Health Insurance for Adults ❑ Veteran's Administration VA Medical Services ❑ Indian Health Services Program ❑ Other Health Insurance ❑ Employer -provided Health Insurance (Specify Source): Revised 4/23/18 OC HMIS: PROJECT INTAKE FORM — CoC/ESG I certify that the information above is correct to the best of my knowledge. Client Signature Agency Staff Signature Date Date DO NOT ANSWER QUESTIONS BELOW — DATA ENTRY PERSONNEL ONLY (Optional): Date entered into HMIS: Question Answer Comments Was the hard copy intake form completely filled out correctly? ❑ No []Yes Staff Name (verifying completion of Data Entry): 6 Revised 4/23/18 Families Forward Exhibit A — Appendix C Declaration of Homelessness DIGNITY • EMPOWERMENT • HOPE Families Forward Housing Program Homeless Certification Applicant Name: 0 Household without dependent children (complete one form for each adult in the household) 0 Household with dependent children (complete one form for household) Number of persons in the household: This is to certify that the above named individual or household is currently homeless based on the check mark, other indicated information, and signature indicating their current living situation. Check only one and complete only that section Living Situation: place not meant for human habitation (e.g., cars, parks, abandoned buildings, streets/sidewalks) 0 The person(s) named above is/are currently living in (or, if currently in hospital or other institution, was living in immediately prior to hospital/institution admission) a public or private place not designed for, or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus station, airport, or camp ground. Description of current living situation: Living Situation: Emergency Shelter 0 The person(s) named above is/are currently living in) a supervised publicly or privately operated shelter or, if currently in a motel where a charitable or government/state agency is paying for the stay. Emergency Shelter Program Name: Living Situation: Transitional Housing 0 The person(s) named above is/are currently living in a transitional housing program for persons who are homeless. The persons(s) named above is/are graduating from or timing out of the transitional housing program: Transitional Housing Program Name: Families Forward DIGNITY • EMPOWERMENT - HOPE I, , have provided Families Forward with 311 party (Client's Name) verification of current housing situation (see attached document). 1*1V I, , certify that the housing information provided (Case manager Name) is accurate by visually inspecting the client's vehicle on (Date) Applicant Name (printed): Applicant Name (signed): Applicant Name (printed): Applicant Name (signed): Case Manager (printed): Case Manager (signed): Date: Date: Date: Date: Date: Date: Families Forw .ZC r Families Forward Exhibit A — Appendix D Housing Quality Standards (HQS) Inspection Checklist Minimum Standards for Permanent Housing Instructions: Place a check mark in the correct column to indicate whether the property is approved or deficient with respect to each standard. The property must meet all standards in order to be approved. A copy of this checklist should be placed in the client file. Approved Deficient Standard (24 CFR part 576.403(c)) 1. Structure and materials: The structure is structurally sound to protect the residents from the elements and not pose any threat to the health and safety of the residents. 2. Space and security: Each resident is provided adequate space and security for themselves and their belongings. Each resident is provided an acceptable place to sleep. 3. Interior air quality: Each room or space has a natural or mechanical means of ventilation. The interior air is free of pollutants at a level that might threaten or harm the health of residents. 4. Water Supply: The water supply is free from contamination. 5. Sanitary Facilities: Residents have access to sufficient sanitary facilities that are in proper operating condition, are private, and are adequate for personal cleanliness and the disposal of human waste. 6. Thermal environment: The housing has any necessary heating/cooling facilities in proper operating condition. 7. Illumination and electricity: The structure has adequate natural or artificial illumination to permit normal indoor activities and support health and safety. There are sufficient electrical sources to permit the safe use of electrical appliances in the structure. 8. Food preparation: All food preparation areas contain suitable space and equipment to store, prepare, and serve food in a safe and sanitary manner. 9. Sanitary condition: The housing is maintained in sanitary condition. 10. Fire safety: a. There is a second means of exiting the building in the event of fire or other emergency. b. The unit includes at least one battery -operated or hard -wired smoke detector, in proper working condition, on each occupied level of the unit. Smoke detectors are located, to the extent practicable, in a hallway adjacent to a bedroom. c. If the unit is occupied by hearing -impaired persons, smoke detectors have an alarm system designed for hearing -impaired persons in each bedroom occupied by a hearing -impaired person. d. The public areas are equipped with a sufficient number, but not less than one for each area, of battery -operated or hard -wired smoke detectors. Public areas include, but are not limited to, laundry rooms, day care centers, hallways, stairwells, and other common areas. 11. Meets additional recipient/subrecipient standards (if any). CERTIFICATION STATEMENT I certify that I have evaluated the property located at the address below to the best of my ability and find the following: ❑ Property meets all of the above standards. ❑ Property does not meet all of the above standards. Program Participant Name: Street Address: Apartment: City: Evaluator Signature: Evaluator Name (Printed): COMMENTS: State: Zip: Approving Official Signature (if applicable): Approving Official Name (if applicable): Date of review: Date: RENT REASONABLENESS CHECKLIST AND CERTIFICATION Proposed Unit UNIT#1 UNIT#2 UNIT#3 ADDRESS NUMBER OF BEDROOMS SQUARE FEET TYPE OF UNIT/CONSTRUCTION HOUSING CONDITION LOCATION/ ACCESSIBILITY AMENITIES UNIT: SITE: NEIGHBORHOOD: AGE IN YEARS UTILITIES (TYPE) UNIT RENT HANDICAP ACCESSIBLE? CERTIFICATION: A. COMPLIANCE WITH PAYMENT STANDARD PROPOSED CONTRACT RENT + UTILITY ALLOWANCE = PROPOSED GROSS RENT APPROVED RENT DOES NOT EXCEED APPLICABLE PAYMENT STANDARD OF B. RENT REASONABLENESS Based upon a comparison with rents for comparable units, I have determined that the proposed rent for the unit f lis f 1 is not reasonable. NAME: SIGNATURE: DATE: Families Forward Exhibit A — Appendix E Landlord Agreement FAMILIES FORWARD DIGNITY • EMPOWERMENT - HOPE Date: To: (Community name, landlord) Address: On Behalf of: (Client name) Families Forward is pleased to inform (Client name) has been approved for housing assistance as of the date of this letter. The primary focus of the Families Forward Housing Program is to help families become self-sufficient. Families Forward will provide supportive services during their tie of assistance. Services that are provided by Families Forward include the following: case management, financial literacy, budgeting, food pantry, home orien- tations, home inspections, holiday programs, career coaching and counseling. Families forward can also assist with rental subsidies that will allow the family to adjust to their new housing commitment. Families Forward will make timely payments to (Community name, landlord) in accordance with the Schedule of Rent Payment attached. Families Forward will make financial assistance payments to (Community name, land- lord), on behalf of the client, using a corporate check. The payments will be mailed or hand delivered by Families Forward staff to the address designated on the lease. Copies of notices given to client during tenancy shall be provided to Families Forward. If tenant is given a notice to vacate unit, or any complaint used under state or local law to commence an eviction action against (Client name), (Community name, landlord) shall also provide a copy of said notice to Families Forward. Move -in date: Payment Due Date: __J__J Monthly Rent; $ Grace Period Late Payment fee: $ The amounts reflected on the schedule of payment may represent the entire or partial amount of rent for each month. (Client Name) shall be responsible for any balance due. In addition, any late fees or penalties incurred are the sole re- sponsibility of (Client Name). By accepting payment you agree to all the terms to the terms noted above. Thank you, 8 Thomas • Irvine, CA 92618• (949) 552-2727• www.families-forward.org• TAX ID# 33-0086043 Families Forward Exhibit A — Appendix F Lease Addendum Families Forward Huntington Beach Tenant Base Rental Assistance Program (Clients Name) has been approved to receive rental assistance under the Huntington Beach Tenant Bases Rental Assistance Program. Under the Tenant Based Rental Assistance Program, Families Forward will make monthly payments to the landlord on behalf of the tenant. The term of the lease shall begin on and shall continue until: (1) the Lease is terminated by the Landlord in accordance with applicable state and local Tenant/ Landlord laws; (2) the Lease is terminated by the Tenant in accordance with the Lease or by mutual agreement during the term of the Lease; or (3) termination of the Tenant Base Rental Assistance Program Contract by Families Forward. Each month Families Forward will provide a rental assistance payment to Landlord on behalf of the Tenant. This payment shall be credited by the landlord towards the monthly rent payable by the Tenant. The balance of the monthly rent shall be paid by the Tenant. Families Forward has assisted Tenant with a Security Deposit of $ that has been provided to the landlord. The Landlord will hold this security deposit during the period the Tenant occupies the dwelling unit under the lease. The Landlord shall comply with state and local laws regarding interest payments on security deposits. After Tenant has moved from the dwelling unit, the Landlord may, subject to state and local laws, use the security deposit including any interest on the deposit, as reimbursement for rent or any other amounts payable by the tenant under the Lease. The Landlord will give the Tenant a written list of all items charged against the security deposit and the amount of each item. After deducting the amount used as reimbursement to the Landlord, the Landlord shall promptly refund the full amount of the balance to the Tenant. The utilities and appliances listed in Column A. (Included in Rent) are provided by the Landlord and included in the rent. The utilities and appliance listed in Column B. (Tenant Paid) below are not included in the rent and are paid separately by the Tenant. UTILITY/ APPLIANCE A. B. Included in Rent Tenant Paid Garbage Collection Water/Sewer Heating Fuel (specify) Lights, electric Cooking Fuel (specify) Other Specify i Refrigerator Stove/ Range Household members authorized to live in this unit are listed below. The Tenant may not permit other persons to join the Household without notifying Families Forward and obtaining the Landlord's permission. Household members: The Landlord agrees to maintain the dwelling unit, common areas equipment, facilities and appliances in decent, safe and sanitary condition. The Landlord may evict the Tenant following applicable state and local laws. The landlord must provide the Tenant with at least 30 days' written notice of the termination. The Landlord must notify Families Forward when eviction proceedings are begun. This may be done by providing Families Forward with a copy of the required notice to the Tenant. Any provision of the Lease which falls within the classification below shall not and not be enforced by the Landlord. (1) Confession of Judgment. Concept by the Tenant to be sued, to admit guilt, or to a judgment in favor of the landlord in a lawsuit brought in connection with the Lease. (2) Treatment of Property. Agreement by the Tenant that the Landlord may take or hold the Tenant's property or may sell such property without notice to the Tenant and a court decision on the rights of the parties. (3) Excusing the Landlord from Responsibility. Agreement by the Tenant not to hold the Landlord or Landlord's agent legally responsible for any action or failure to act, whether intentional or negligent. (4) Waiver of Legal Notice. Agreement by the Tenant that the Landlord may institute a lawsuit without notice to the Tenant. (5) Wavier of Court Proceedings for Eviction. Agreement by the Tenant that the Landlord may evict the Tenant Family (1) without instituting a civil court proceeding in which the Family has the opportunity to present a defense, or (ii) before a decision by the court on the rights of the parties. (6) Wavier of Jury Trial. Authorization to the Landlord to wave the Tenants right to a trial by jury. (7) Wavier of Right to Appeal Court Decisions. Authorization tothe Landlord to waive the Tenant's right to appeal a court decision or waive the Tenant's to sue prevent a judgement from being put into effect. (8) Tenant Chargeable with Cost of Legal Actions Regardless of Outcome of Lawsuit. Agreement by the Tenant to pay lawyer's fees or other legal costs whenever the Landlord decides to sure, whether or not the Tenant wins. The Landlord shall not discriminate against the Tenant in the provision of services, or in any other manner, on the grounds of age, race, color, creed, religion, sex, handicap, national origin, or familial status. Tenant Signature Landlord Signatures By: By• Print Name: Print Name: Signature/ Date: By: Print Name: Signature/ Date: By: Print Name: Signature/ Date: Signature/ Date: Families Forward Exhibit A — Appendix G Rent Reasonable RENT REASONABLENESS CHECKLIST AND CERTIFICATION Proposed Unit Unit #1 Unit #2 Unit #3 Address Number of Bedrooms Square Feet Type of Unit/Construction Housing Condition Location/ Accessibility Amenities Unit: Site: Neighborhood: Age in Years Utilities (type) Unit Rent Handicap Accessible? CERTIFICATION: A. Compliance with Payment Standard Proposed Contract Rent + Utility Allowance = Proposed Gross Rent Approved rent does not exceed applicable Payment Standard of B. Rent Reasonableness Based upon a comparison with rents for comparable units, I have determined that the proposed rent for the unit [ ]is [ ] is not reasonable. Name: Signature: Date: 11 Families Forward Exhibit A — Appendix H Orange County Housing Authority Utility Allowance Schedule Mr ca R A N G F ODICCOMmunitv Resources 2018 Utility Allowances for Housing Choice Voucher Program The following Utility Allowances will be used by the Orange County Housing Authority (OCHA) for administration of the Housing Choice Voucher Program effective November 1, 2017. Bedroom 1 0 1 1 2 1 3 4 1 5+ ." � I, si //.H' � Cookin 2 3 1 4 1 5 6 8 Heating 11 13 15 1 16 17 19 Water Heating 6 7 10 14 18 22 .:" : �,, Basicx 20 23 33 46 59 73 Cooking 4 5 9 13 17 20 Heating 15 18 20 22 24 28 Water Heating 11 15 22 27 32 37 It Water 31 32 1 44 63 1 81 1 100 Trash/Sewer 26 Refrigerator 9 Stove 7 ®range County Housing Authority 1 770 N. BROADWAY, SANTA ANA CA. 92706 0 PHONE (714) 480-2700 FAX (714) 480-2945 Families Forward Exhibit A — Appendix I Participation Agreement FAMILIES FORWARD DIGNITY - EMPOWERMENT • HOPE Families Forward Housing Program Contract Families Forward provides a Housing Program for families who are without housing and who do not have the financial resources to provide housing for themselves. No distinction is made regarding admittance based on race, religion, age, sex or ethnic origin. 1. The rent is due on or before the first of each month. 2. Tenant is to provide a copy of rent payment receipt by the 3rd of each month. 3. Each tenant will receive support in maintaining a monthly budget. Monthly meetings will be scheduled to verify income, expenses and collect pay stubs in order to complete the monthly budget. 4. Tenant is to maintain communication with the Case Manager with regards to progress, problems, change in employment status or other concerns. 5. Families Forward Staff are mandated reporters, which are professionals, required by law to report any reasonable suspicion of abuse or neglect inflicted on children and/or dependent adults. Any investigations will be conducted by law enforcement, county agency and/or the child welfare department to determine if abuse or neglect has occurred. 6. Tenant is responsible for keeping the property clean and well maintained at all times. 7. Tenant will allow for home inspections to be completed on the property by the Housing Resource Specialist and Case Manager. The family may or may not be present at the time of the inspection. These home inspections will be done twice a month and Housing Resource Specialist will inform family of the predesignated days of the month during Home Orientation. 8. Tenant has access to a Housing Resource Specialist and may complete a Tenant Screening. Tenant can have regular check -ins until housing is identified. These meetings will include discussions on housing options in Orange County, current market rates by area, and barriers and strategies to circumvent these issues. 9. Families Forward reserves the right to terminate housing assistance in the event the tenant violates regulations outlined in the lease and/or rental agreement. 10. It is a violation of the agreement to allow anyone not stated on the lease to assume residence in the tenant's property. 11. Families Forward Staff will assist the tenant as appropriate to achieve self-sufficiency. Applicant Date Case Manager Date Applicant Date Families Forward Families Forward Exhibit A — Appendix J Case Management Policies and Procedures FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE Families Forward Intake Process The Housing Intake Coordinator (HIC) oversees the intake process for all Literally Homeless families that complete a Request for Services (RFS) form. The HIC will call back all literally homeless families between 24-48 hours after submission of the RFS - Literally Homeless Definition An individual or family who lacks a fixed, regular, and adequate nighttime residence, which includes a primary nighttime residence of., o Place not designed for or ordinarily used as a regular sleeping accommodation (including a car, park, abandoned building, bus/train station, airport, or camping ground) o A supervised publicly or privately operated shelter designated to provide temporary living arrangements (including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state, or local government programs) o Or an individual is considered homeless if she or he is being discharged from an institution where she or she has been a resident for 94 days or less and the person resided in a shelter (not transitional housing) or place not meant for human habitation immediately prior to entering that institution Families in need call Families Forward and speak to a volunteer that collect basic information and complete a Request for Services (RFS) Form (see attached RSF form) The HIC will review the RFS to determine who meets the criteria for assistance, - The family must be literally homeless - There must be at least one minor aged child in the household and the parent(s) must have at least 50% custody of their child(ren) Those that meet the criteria will receive a call from the HIC to verify the information on the RFS, explain the Intake and Coordinated Entry process, HIC will then schedule an appointment to complete the Vulnerability Index - Service Prioritization Decision Assistance Tool (VI-SPDAT) see following page for copy of VI-SPDAT. The VI-SPDAT tool is utilized by the entire Continuum of Care to prioritize homeless persons seeking help. An accurate score is calculated from the VI-SPDAT, which ensures that the most vulnerable persons are receiving immediate service without bias. FAMILIES FORWARD DIGNITY - EMPOWERMENT • HOPE Score ranges and housing intervention: - 0-3 No Housing Intervention - 4-8 Rapid Re -Housing - 9+ Permanent Supportive Housing (chronically homeless and disabled) or Orange County Housing Authority Voucher Program (NOT chronically homeless and/or disabled) See below for an outline of a typical phone call with a client. Phone call: Hello, this is the Housing Intake Coordinator calling from Families Forward. The reason for my call is to review the information on your Request For Services form received on (date). Do you have 20-30 minutes to review this information with me? The HlC may ask the following questions based on the information on the RFS. - Has anything changed since you last called? - Adult(s): Is your name ? What is your date of birth? Do you have any other adults in the household i.e. adult child, grandparent, aunt, uncle? - Employment/Income: It says here that you are working at (company) for (time) and are making per month. Is this correct? Partner's employment status? If collecting Cashaid/Calworks/SSI, how long/how much? - Current living situation: It says here that you are currently staying in In the city of . Is that still accurate? Where did you sleep last night? If so, how long? How long have you been looking for housing? Is your current environment safe? - Children: What are the ages of your children? Are there any children that are not living with you now, that may live with you when you find permanent housing? - Program history: Are you currently working with any other program(s)? If so, can you provide a program letter of verification? Have you completed a VI-SPDAT with that or any other agency? Explain what a VI-SPDA T is. - Plan: Have you reached out to an emergency shelter? Have you reached out to an agency or Social Services for access to a motel voucher? DO you want or need any additional resources to bridge the time before you are matched? FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE HIC will give a brief overview of the intake process: - Families Forward does offer a Rapid Re -Housing program that helps families identify permanent housing and offers rental subsidies for families to help them get back on their feet. This is a short term assistance program and is 1-3 months long. - Along with rental assistance, we provide supportive services through case management such as budgeting assistance (as you are required to maintain a monthly budget), career coaching, food pantry, counseling, and referrals to resources within the community as needed by the family. - in addition, we conduct monthly home inspections to make sure your apartment is clean and safe. - Families Forward, along with other agencies that offer Rapid Re - Housing assistance, participate in Coordinated Entry System (CES). As part of CES, all agencies must submit the information from the VI- SPDAT. CES oversees this process for Orange County. The information is gathered by CES and families are placed on a prioritization list based on the needs and preferences of the family. From that list, families are matched to an agency depending on their availability. Since CES oversees the matching process, your family may or may not be matched to Families Forward. All families are matched to an agency that offers a Rapid Re -Housing program. Once a family is matched, that agency will call you with next steps. A typical timeframe to be matched can take a few days to a few weeks. HIC will ask the family to bring in documentation to verify their current housing status. If the family is in: O An emergency shelter, client must bring in a program letter on letterhead from the agency o A motel, then client must bring an award letter from the Social Services and/or program letter on letterhead from the agency or church O A place not meant for human habitation, such as a car, the HIC will personally inspect the car - The next step in the intake process is to schedule a 1st meeting to complete the VI-SPDAT. All the adults must be present for the VI- SPDAT. This meeting is approximately an hour long. 1st Meeting_ The meeting will take place in the office of the HIC. During this meeting, the HIC will meet one on one with the client and have him complete the following documents: FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE - VI-SPDAT - HMIS Consent Form Homelessness Certification c Client to sign Homelessness Certification and provide supporting homeless documentation from agency, emergency shelter, church and/or social service agency c If client is stating the family is sleeping in their car, HIC will complete a car inspection in the FF parking lot, HIC will sign Homelessness Certification verifying homelessness VA Form 10-5345 for Veteran clients HIC will proceed with the questions on the VI-SPDAT. Upon completion, HIC will allow time for any follow-up questions from the family, VI-SPDAT submissions to CES: HIC will submit all VI-SPDAT assessments, HMIS Consent Forms and Homelessness Certifications no later than 12PM every Friday to CES. VI- SPDAT assessments are submitted via a CES google doc link, The other supporting documents are encrypted and password protected, then sent to CES via email. A family that does not have all the required documentation to submit to CES is not considered "document ready" and will not be matched to an agency until they complete the above mentioned forms. Along with the VI-SPDAT submissions, HIC will notify CES every Friday of any Families Forward housing opportunities via google doc. Families Forward bases these housing opportunities on the caseload capacity of the Case Managers. Matches to Families Forward: Every week, the HIC will receive matches from CES based on the housing opportunities submitted from the previous week. This information is sent via email with a secured attachment, password protected, of personal client information. HIC will call client within 24-48 hours for introduction of program and next steps to complete the program enrollment process. FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE The HIC will meet with the Housing Program Manager to discuss Case Manager (CM) and grant assignment for the weekly matches. HIC will provide the client contact information to the CM. For families that have been matched to Families Forward and CM is unable to connect with them after 3 attempts with 3 different forms of communication (i.e. text, phone call, email), those families will be returned to CES. HIC will check in with the CM on a weekly basis to gather this information. Coordinated Entry Intake for Families Basic Information- Ia. Street Outreach Team or In -Reach Site: lb. Interviewer's Name: 1c, Survey Date: 1d. Survey Time: le. Survey Location (City): 3. Will you be completing the full assessment? ❑ Yes (CE Intake, VI-SPDAT and Housing Preference Survey) Go to Intake for Head of Household ❑ No (Name Only) Go to By Name Only Head of Household —Client Identification 1. First Name: 3. Last Name: 2. Middle Name: 2a. Suffix: 2b, Alias: 4. Date of Birth: 5. Social Security Number (last 4 digits): ❑ Full DOB reported ❑ Approximate or partial SSN reported ❑ Approximate or partial DOB ❑ Client Doesn't Know ❑ Client Doesn't Know ❑ Client Refused ❑ Client Refused ❑ Data not Collected ❑ Data not Collected Contact Information — Do you have a number and/or email where I can follow uo with you or leave a message? 6. Main Phone #: ( ) - ext. ❑l Message/VM okay Contact Preference 6a. Alternate Phone €#: - ❑ Phone ( ) ext. ❑ Message/VM okay 7. Email: @ ❑ Text ❑ Email Flead of Household -Demographics 8. Gender: 9. Do you have a disability? 10. Have you ever served in the ❑ Male (Physical, Developmental, Mental U.S. Armed Forces? ❑ Female Health, Chronic Health Condition, ❑ Yes 4 please administer VA ❑ Transgender Female to Male HIV/AIDS, and/or Substance Use release of information ❑ Transgender Male to Female Disorder,) ❑ No ❑ Client Doesn': Know ❑ Yes ❑ Client Doesn't Know ❑ Client Refused ❑ No ❑ Client Refused ❑ Data not Collected ❑ Client Doesn't Know ❑ Data not Collected ❑ Other: ❑ Client Refused ❑ Data not Collected 11. Education Level - What is the highest degree or level of school you have completed? If currently enrolled, highest degree received. ❑ No Schooling Completed ❑ 111h Grade ❑ 4-years College Degree ❑ Nursery School to 411 Grade ❑ 12th Grade, no diploma ❑ Graduate School ❑ 51h or 61h Grade ❑ High School Diploma ❑ Client Doesn't Know ❑ 711 or V Grade ❑ GED ❑ Client Refused ❑ 9tn Grade ❑ Post -Secondary School ❑ Data not Collected ❑ 101" Grade Client Name: VI -SPRAT for Families, American Version 2.0--obtained from http://www.orgcode.com/ HISTO Y EHQL(5'I G` D HQNIELES�SNE S- $ , 1. Where do you and your family sleep most Address: frequently? (check one) 1a. Intersection: ❑ Shelter ❑ Transitional Housing 1b. Landmark: ❑ Safe Haven El Outdoors zc. City: 1d. Zlp Code: ❑ Others (specify): ❑ Same as above ❑ Refused 2. How long has it been since you (and your family) lived in permanent stable housing? 3. In the past three years, how many times have you (and your family) been homeless and then homeless again? 4. In the last three years, what is the total number of months spent homeless on the streets, in an emergency sneiter, or place not meant for human habitation? '. s sg>Y✓,,,n xNO , ,Nq 5. In the past six months, how many times have you or anyone In your family... a. Received health care at an emergency department/room? ❑ Refused b. Taken an ambulance to the hospital? ❑ Refused c. Been hospitalized as an inpatient? ❑ Refused d. Used a crisis service, including sexual assaults crisis, mental health crisis, family/intimate violence, distress centers, and suicide prevention hotline? ❑ Refused e. Talked to police because they witnessed a crime, were the victim of a crime, or the alleged perpetrator of a crime, or because the police told you that they must move along? ❑ Refused f. Stayed one or more nights in a holding cell, jail or prison, whether that was a short-term stay like the drunk tank, a longer stay for a more serious offense, or anything in between ❑ Refused 5. Have you or anyone in your family been attacked or beaten up since []Yes ❑ No ❑ Refused they've become homeless? 7. Have you or anyone in your family threatened to or tried to harm ❑ Yes ❑ No ❑ Refused themselves or anyone else in the last year? S. Do you or anyone in your family have any legal stuff going on right now ❑ Yes ❑ No ❑ Refused that may result in them being locked up, having to pay fines, or that make it more difficult for you to rent a place to live? ❑ Yes ❑ No ❑ Refused Client Name: 9. Does anybody force or trick you or anyone In your family to do things that ❑ Yes you do not want to do? 10. Do you or anyone in your family ever do things that may be considered risky like exchange sex for money, run drugs for someone, have unprotected sex with someone you don't know, share a needle, or ❑ No ❑ Refused 11. Is there any person, past landlord, business, bookie, dealer, or government ❑ Yes ❑ No ❑ Refused group like the IRS, that thinks you or anyone in your family owe them money?? 12. Do you or anyone In your family get any money from the government, a ❑ Yes ❑ No ❑ Refused pension, an Inheritance, working under the table, a regular job, or anvthina like that? 13. Does everyone in your family have planned activities, other than just ❑ Yes ❑ No ❑ Refused surviving that make them feel happy and fulfilled? 14, Is everyone in your family currently able to take care of basic needs like. ❑ Yes ❑ No ❑ Refused bathing, changing clothes, using a restroom, getting food and clean water, and other things like that? 15. Is your family's current homelessness in any way caused by a relationship ❑ Yes ❑ No ❑ Refused that broke down, an unhealthy or abusive relationship, or because family or friends caused you to become evicted? 16. Has your family ever had to leave an apartment, shelter program or other ❑ Yes ❑ No ❑ Refused place you were staying because of the physical health of you or anyone in your family? 17. Do you or anyone in yourfamily have any chronic health issues with your ❑ Yes ❑ No ❑ Refused liver, kidneys, stomach, lungs or heart? 18. If there was space available in a program that specifically assists people ❑ Yes ❑ No ❑ Refused that live with HIV or AIDS, would that be of interest"to you or anyone in your family? 19. Does anyone in your family have any physical disabilities that would limit ❑ Yes ❑ No ❑ Refused the type of housing you could assess, or would make it hard for you to live Independently because you'd need help? 20, When someone in your family is sick or not feeling well, does your farnily ❑ Yes ❑ No 1=1 Refused avoid getting medical help? 21. IF THE HOUSEHOLD INCLUDES A FEMALE: Is any member of the family ❑ Yes ❑ No ❑ Refused currently pregnant? 22. Has drinking or drug use by you or anyone in yourfamily led yourfamily ❑ Yes ❑ No ❑ Refused to being kicked out of an apartment or program where you were staying In the past? Client Name: 23. Will drinking or drug use make it difficult for your family to stay housed or ❑ Yes ❑ No ❑ Refused afford your housing? 24. Has your family ever had trouble malntaining your housing, or being kicked out of an apartment, shelter program or other place you were staying, or because of: a. A mental health issue or concern? ❑ Yes ❑ No ❑ Refused b. A past head injury? ❑ Yes ❑ No ❑ Refused c. A learning disability, developmental disability, or other impairment? ❑ Yes ❑ No ❑ Refused 25. Do you or anyone in your family have any mental health or brain issues ❑ Yes ❑ No ❑ Refused that would make it hard for your family to live independently because g�63.� Ir- THE FAMILY SCURED .I EACH FOR PHYSICAL HEALTH, SUBSTANCE USE, ❑ Yes ❑ No ❑ N/A or AND MENTAL HEALTH: Does any single member of your household have a Refused medical condition, mental health concern, and experience with atic substance use? 26. Are there any medications that a doctor said you or anyone in your family ❑ Yes ❑ No ❑ Refused should be taking that, for whatever reason, they are not taking? 27. Are there any medications like painkillers that you or anyone In your family ❑ Yes ❑ No ❑ Refused don't take the way the doctor prescribed or where they sell the medication? [ e. ESTt7 j1..%k 28. YES or NO: Has your current period of homelessness been caused by an ❑ Yes ❑ No ❑ Refused experience of emotional, physical, psychological, sexual, or other type of abuse, or by any other trauma you have experienced? 29. What best describes this household? ❑ Single Parent ❑ Two Parent 30. How many children under the age of 18 are currently with you? 31. How many children under the age of 18 are not currently with your family, but you have reason to believe they will be joining you when you get housed? 32. Please provide a list of children's names and ages: First Name last Name ❑ Refused ❑ Refused Client Name: 33, Are there any children that have been removed from the family by a child ❑ Yes ❑ No ❑ Refused protection service within the last 180 days? 34. Do you have any family legal issues that are being resolved in court; or need ❑ Yes ❑ No ❑ Refused to be resolved in court that would impact your housing or who may live within vour housing? 35. In the last 180 days have any children lived with family or friends because of your homelessness or housing situation? 36. Has any child in the family experienced abuse or trauma in the last 180 days? 37. IF THERE ARESCHOOL-AGED CHILDREN: Do your children attend school more often than not each week? 38. Have the members of your family changed in the last 180 days, due to things like divorce, your kids corning back to live with you, someone leaving for military service or incarceration, a relative move In, or anything like that? 39. Do you anticipate any other adults or children coming to live with you ❑ Yes ❑ No ❑ Refused ❑ Yes ❑ No ❑ Refused ❑ Yes ❑ No ❑ Refused ❑ Yes ❑ No ❑ Refused ❑ Yes ❑ No ❑ Refused �-3"• r.,-Ptm�sR.-r+? � F.�.�.i'.v"§�P'%�'�v*�� ��r r -x..# x ^Y. 4d r -t r!- h�;a��i'`3�ifx�' $,��-f. �x�, -` �i��'.t s tw.. �{�' r�.s3"'^'�.'i"Ii:,�r�,t�,�''i�� ,''•. � � � a � *a. G�...• .e«..-, �,. ,,:�:c �, ..-3�;.<0,... r.:!...w �,..'fa• � ra..< ..�.�: � ;r�v.:,a..: ,_ � _ ,�.# •i.v�1,C.c�. �s�y.::lr� �T 40. Do you have two or more planned activities each week as a family such as ❑ Yes ❑ No ❑ Refused outings to the park, going to the library, visiting other family, watching a family movie, or anything like that? 41. After school, or on weekends or days when there isn't school, is the total time children spend each day where there is no interaction with you or another responsible adult — a. 3 or more hours per day for children aged 13 or older? ❑ Yes ❑ No ❑ Refused b. 2 or more hours per day for children aged 12 or younger? ❑ Yes ❑ No ❑ Refused 42. IF THERE ARE CHILDREN BOTH 12 AND UNDER & 13 AND OVER: Do your []Yes ❑ No ❑ N/A or older kids spend 2 or more hours on a typical day helping their younger Refused Client Name: slbling(s) with things like getting ready for school, helping with homework, making them dinner, bathing them, or anything like that? Scoring Summary Subtotal Results Page Total A Score Recommendations 0-3 No housing intervention 4-8 Assessment for Rapid Rehousing 9+ Assessment for Permanent Supportive Housing Page Total B Page Total C Page Total D Page Total E Grand Total Housing Preference Survey— PSH Client Name: 1. What city within the County of Orange, do you live In? 2. Which of the following communities would 3. Which of 4. Which of S. Where are you be your FIRST choice for housing? the the NOT willing to ❑ Anywhere within Orange County (wherever I following following accept housing? am most likely to be placed into housing the communitie communitie ❑ North quickest) Skip to 6 s would be s would be ❑ South ❑ North ❑ East your your THIRD ❑ East ❑ South ❑ West SECOND choice for ❑ West choice for housing? housing? ❑ North ❑ North ❑ South ❑ South ❑ East ❑ East ❑ West ❑ West ❑ Not ❑ Not Applicable Applicable 6. Do you have any ties to the Civic Center? 7. How many adults, including yourself, will be living in ❑ Yes the unit? ❑ No ❑ 1 ❑ 2 ❑ 3 ❑ 4+ 7a. If one or more adults In addition to you will S. Are all adults in the household authorized to work in be living in the unit, please list each adult and the U.S.? his/her relation to you. ❑ Yes, all adults are authorized to work in the U,S. ❑ Not Applicable ❑ Some adults, but not all adults are authorized to work Name: in the U.S. Relation: ❑ No adult is authorized to work in the U.S. Name: Relation: 9. If you were able to locate housing, do you 10. What is your household's monthly income? Include have money saved up for move•in or the income of all adults (18 years of age and older) who housing? will be living with you. ❑ Yes $ . ❑ No 11. Have you ever been evicted or received 11a. If yes to eviction, do any of the following notice to leave from housing or abandoned a situations apply to you? unit, of which your name was on the lease? ❑ Evicted due to fraud. ❑ Yes, evicted. ❑ Evicted due to unit damage ❑ Yes, received notice to leave. ❑ Owe money to property manager ❑ Yes, abandoned a unit. ❑ Not Applicable ❑ No ❑ Client Refused ❑ Client Doesn't Know ❑ Client Refused Client Name: Additional Adults in the Household —Total #: ❑ No additional adults in the household. 1.First Name: E. Last Name: l 2a. Middle Name: 2b. Suffix: 2c. Alias: 4, Date of Birth:�_ / S. Social Security Number: - ❑ Full DOB reported ❑ Full SSN reported ❑ Approximate or partial DOB ❑ Approximate or partial SSN reported ❑ Client Doesn't Know ❑ Client Doesn't Know ❑ Client Refused ❑ Client Refused ❑ Data not Collected ❑ Data nct Collected 8. Gender: 9. Do you have a disability? 10. Have you ever served in the ❑ Male (Physical, Developmental, Mental U.S. Armed Forces? ❑ Female Health, Chronic Health Condition, ❑ Yes —> please administer VA ❑ Transgender Female to Male HIV/AIDS, and/or Substance Use release of information ❑ Transgender Male to Female Disorder) ❑ No ❑ Other: ❑ Yes ❑ Client Doesn't Know ❑ Client Doesn't Know ❑ No ❑ Client Refused ❑ Client Refused ❑ Client Doesn't Know ❑ Data not Collected ❑ Data not Collected ❑ Client Refused ❑ Data not Collected 11. Education Level —What is the highest level of education you've completed? ❑ No Schooling Completed ❑ 111h Grade ❑ 4-years College Degree ❑ Nursery School to 411 Grade ❑ 12th Grade, no diploma ❑ Graduate School ❑ 5th or 6th Grade ❑ High School Diploma ❑ Client Doesn't Know ❑ 7t1 or 811 Grade ❑ GED ❑ Client Refused ❑ 91hGrade ❑ Post -Secondary School ❑ Data not Collected ❑ 10t11 Grade 12. Which category best describes your race? (Check All that _ 13. Which category best describes your Apply): ethnicity? ❑ Asian ❑ Client Doesn't Know ❑ Non -Hispanic ❑ Black or African American: ❑ Client Refused ❑ Hispanic ❑ Native Hawaiian/Other Pacific ❑ Data not Collected ❑ Client Doesn't Know Islander ❑ Client Refused ❑ American Indian/Alaska Native ❑ Data not Collected ❑ White Client Name: 12. Which category best describes your race? (Check all that 13. Which category best describes your Apply), ethnicity? ❑ Asian ❑ Client Doesn't Know ❑ Non -Hispanic ❑ Black or African American ❑ Client Refused ❑ Hispanic ❑ Native Hawaiian/Other Pacific ❑ Data not Collected ❑ Client Doesn't Know Islander ❑ Client Refused ❑ American Indian/Alaska Native ❑ Data not Collected ❑ White LUGd UUII IIIIVI II Id LIUI I — UII d I CrW dJ VIM y, wnere is It edsieJL t:e rma yclu area your rams iyr 14. On a regular day, where is it easiest to find you? 14a. Intersection: ❑ Street ❑ Vehicle ❑ Abandoned building ❑ Bus/train/subway station/airport El Drop in Center 14b.Landmark: ❑ Day Services Center ❑ Soup Kitchen ❑ Emergency Shelter ❑ Transitional Housing 14c. City: ❑ Permanent Housing ❑ Clinic/Hospital — Health ❑ Clinic/Hospital —Mental Health 14d. Zip Code: ❑ Clinic/Hospital—Substance Abuse ❑ Jail, prison, or juvenile detention facility ❑ Family or friend's roam, apartment, condo, or house ❑ Foster care or group home ❑ Other (specify): Housing Preference Survey — PSH Client Name: 12. Have you ever been evicted from a 13. Have you ever 14. If yes, please describe all felonies Public Housing Authority (PHA) units? been convicted for which you have been ❑ Yes of a felony? convicted? ❑ No ❑ Yes ❑ Not Applicable ❑ No ❑ Client Refused ❑ Client Refused ❑ Not Applicable 15. Have you ever been convicted of.....? 16. Are you a registered sex offender? ❑ Felonies considered violent ❑ Yes ❑ Manufacturing or producing methamphetamine ❑ No ❑ Arson ❑ Client Doesn't Know ❑ Not Applicable ❑ Client Refused ❑ Client Refused 17. Are you currently on probation or parole? ❑ No ❑ Probation ❑ Both ❑ Parole 18. To the best of your knowledge, do you (or anyone in your ❑ Yes ❑ Client ❑ Client family) have any active warrants? ❑ No Doesn't Refused Know 19. Are you (or anyone in your farnily) receiving 19a. If yes, what agency provides those supportive supportive services that can/will follow you services? into permanent housing? ❑ Yes ❑ Not Applicable ❑ No ❑ Client Refused 20. Are you linked to a Care Coordinator/Case Manager/ Mental Health Program/ ❑ Yes Behavioral Health Clinic? ❑ No ❑ Client Doesn't Know ❑ Client Refused 21. Do you have a pet or companion/ service 21a. If yes, what type of pet? animal? ❑ Dog ❑ Pet ❑ Cat ❑ Companion Animal ❑ Other: ❑ Service Animal ❑ Not Applicable 21b. If yes, how many? ❑ 1 ❑ Client Refused ❑ 2 ❑ 3 ❑ 4t ❑ N/A Housing Preference Survey — PSH Client Name: 22. Do you require or request a ground floor 23, Do you require or request parking unit? accommodations? ❑ Yes, due to physical disability ❑ Yes, for vehicle ❑ Yes, due to preference ❑ Yes, for RV/Trailer ❑ No ❑ No ❑ Client Refused ❑ Client Refused 24. Are you open to shared housing? 25. Have you been in shared housing? ❑ Yes ❑ Yes ❑ No ❑ No 25a. If so, how was your experience? 26. Are you interested in..? ❑ 1 ❑ Shelter Plus Care ❑ 2 ❑ STAY, housing program for youth ❑ 3 ❑ 4 ❑ S 27. Are there other requirements or request NOTES: around permanent housing that we need to be aware of? North South East West • Anaheim • Aliso Vieio • Laguna Niguel • Costa Mesa • Cypress * Atwood + Balboa 0 Laguna Wood • El Modena • Fountain Valley • Brea . • Capistrano 0 Lake Forest • Irvine Huntington Beach • Buena Park Beach Mission Viejo . Lemon Heights • Los Alamitos • Fullerton Corona del 0 Rancho Mission Newport Beach Midway City • Garden Greve Mar Viejo • Orange • Sea' Beach • La Habra a Dana Point Rancho Santa • Santa Ana • Sunset Beach • La Palma 6 Ladera Ranch Margarita . Tustin • Westminster • Placentia 0 Laguna Beach • San Clemente a Villa Park • Stanton + Laguna Hills San Juan Capistrano • Yorba Linda FAMILIES FORWARD DIGNITY - EMPOWERMENT • HOPE Enrollment Process: a Once CM receives match, CM will call client within 24-48 hours to schedule appointment for Packet Review and Tenant Screening with CM and HRS ■ Appointment takes approximately 2 hours to complete • CM to send calendar and google doc invite to HRS for date and time of appointment o Client to bring the required family documents: ■ Proof of Income (one month's worth, last 3 paystubs) ■ Birth certificates • ID's for adults • Social security cards ■ Immunization records for children 0-S or school enrollment verification for children 5+ ■ Medical cards ■ Current pay stubs or any other income source ■ Bank statements • Car registration and insurance • Custody/court documentation (If applicable) • Disability forms (if applicable) • Include Dara Entry Clerk to calendar invite (availability to attend appointment based on DEC capacity) o DEC will make copies of all family documents during appointment • Begin Enrollment Process (Packet Review and Tenant Screening): o CM to start meeting with review of homeless certification from CES ■ CM to gather current documentation from client • CM to provide Homeless Certification form for client to sign and date, as well as provide the homeless documentation from agency, emergency shelter, church and/or social service agency ■ If client is stating the family is sleeping in their vehicle, CM will complete a vehicle inspection in the FF parking lot, CM will sign Homelessness Certification verifying homelessness FAMILIES FORWARD DIGNITY - EMPOWERMENT • HOPE c Once the documentation is collected, CM will proceed with the Packet Review o For any family that does not re -certify and/or cannot provide the above information, will be sent back to CES ■ CM to update HIC with this information ■ HIC will send update to CES on a weekly basis o CM will gather all family documents and hand over to DEC o HRS will conduct Tenant Screening in which housing history and credit report will be reviewed o For packet review, CM will fill out an enrollment packet for each member of the household ■ CM to use this time to ask about family and homeless history CM will also review and verify income documentation provided by client. Adults earning any form of income must sign the Self Declaration of Income and provide any of the following forms of verification that are applicable: ■ Last 3 paystubs for earned income ■ If paystubs are not available, then an offer letter as it relates to a new job, that has not yet started, can be submitted ■ An award letter on letterhead for Cashaid, Disability and/or SS[ ■ Court paperwork as it relates to child support or alimony ■ If the above mentioned documents are unavailable and CM has done their due diligence in trying to obtain documents (as noted in emails and/or case notes) CM will use the Self Declaration of Income as proof of income for the family o CM will plug in this information into the Income Calculation Worksheet to determine if family meets income guideline requirements o Based on the information, circle the income bracket the family falls under on the annual HUD guidelines document ■ CDBG participants must fall under extremely low to low-income bracket o Once packets are completed, CM will explain and obtain client(s) signature on all program documents during appointment FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE • Complete Enrollment Process O CM will submit the completed HMIS packets and family documents to DEC to enter information in both HMIS and Client Track Systems O CM will receive client information from Data Entry Clerk (DEC) after client information is entered into both Client Track and HMIS systems ■ DEC will provide information to CM within 24 hours • CM will pull an HMIS report and Background Check on all adults in the household Note: o What program is the family entering (Interim Transitional Housing- I- TH or Rapid Re -housing)? ■ All I-TH clients are required to complete a drug screen prior to program entry as part of a needs assessment and not as a determinant of program entry ■ CM provides a referral to all of the adults in the household to complete a drug screening at a predesignated location • Clients must complete the Packet Review and Tenant Screening in order to complete enrollment into the housing program • Active vs Pending Clients o Once the enrollment process is completed, CM will maintain a caseload consisting of both Active and Pending clients a Active clients- homeless families that are currently in Interim Transitional Housing or Rapid Re -Housing Programs • Pending clients- homeless families that have been matched to Families Forward and have completed the enrollment process, but have yet to identify permanent housing • CM and HRS must check in weekly with family until housing is identified • Family will be sent back to CES for non-compliance with program rules or ceases communication with CM FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE Family Move in Process Interim Transitional Housing: • Prior to all move -ins, the client must be given a drug screening referral and submit for a background check c Review results with Housing Program Manager • CM sends Interim move -in request to Housing Resource Specialist (HRS) via google doc and calendar invite to schedule date and time • Property Coordinator will meet with the family to review lease agreement o The family's rent amount will be calculated using the Rental Formula form with the included chart below Tier Rent Monthly Household Income 0 $100 Below $850 1 $200 $851- $1500 2 1 $300 $1501- $2500 3 1 $500 Above$2501 o Rent will not exceed 30% of client's gross income as stated in ■ Proof of income ■ Client self -declaration of income ■ Or signed intake form o A $500 deposit is required for move -in into interim housing o During this time CM can prepare food/toiletry bags for family • CM will lead second half of lease signing meeting; o CM will go over program expectations/guidelines/agreements • During this meeting CM will go over the following documents; o Termination of assistance process of policy o Termination of housing assistance process of appeals c Transitional housing application process c Misconduct act c Exhibit A o Program contract o Rent Amendment o Community cares forms • Give copies of documents to client • Give client directions and address to Interim Transitional Housing unit o Families Forward staff will go in pairs to escort the family to the unit o Family will follow you in their own vehicle to the home o Prior approval is needed if CM plans on having the family in their personal vehicle • Take family on a tour of the home • Before leaving the home let family know you will be in contact with them in the next 2 days to make their first family meeting appointment FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE Rapid Re -Housing: • Client and/or landlord to send over W9 and copy of unsigned lease/move-in statement to CM • CM to evaluate/ create Schedule of Rent Payment (SORP) • CM to submit check request to accounting with copy of unsigned lease/move- in, W9 and SORP o Check requests are process every Wednesday ■ Only emergency check requests will be processed outside of that time frame o Check requests that are over $1000 need two signatures from a Director and/or Manager o Check requests that are under $1000 need only one signature from a Director and/or Manager • Request copy of signed lease as soon as its available from client or landlord o Get this from apartment community or client o Save signed lease copy in the "G Drive" • Apartment community will be sent copies of below documents by CM: o Communication disclosure o Program contract o Apartment Inspection o SORP • Set up 15i family meeting • Set up home orientation with Housing Resource Specialist o Client is responsible for setting up this appointment o CM is responsible for giving client contact information for Housing Resource Specialist WAI V I I a 12 M W01CT/%Z10-1 DIGNITY • EMPOWERMENT • HOPE Family Meetings Preparation for Initial family meeting • Meet with Housing Program Manager to review all current family barriers o This information with will be used to develop a CTI plan • The following information will be included in clients CTI plan o Name of adults in household o Date the CTI plan was created o Phase 1 ■ Assessment of the family and their support network, decide on areas of focus, begin connecting to appropriate resources o Phase 2 ■ Evaluate progress with areas of focus and connections to those areas o Phase 3 ■ Finalize all connections made to areas of focus, ■ Family will have identified continuous support, program end O Areas of Focus ■ CM and client will collaborate on the areas of focus ■ Areas of focus are goals with action steps listed for each phase ■ 6 areas of focus include. counseling and psychiatric treatment, career coaching, substance abuse treatment, housing crisis prevention & management, and family intervention O Recertification/Extension ■ If a client requests or CM feels the need to extend the time in the program, the CM will present recommendations and progress for the family to the housing committee during the case management meeting at least a month prior to exit Initial family meeting • During the initial family meeting the following items will be reviewed with the family o Client Handbook ■ Review the Client Handbook with the family • The purpose of the client handbook is to allow for the family to have an organized tangible place to keep all documents that they receive and to have a place to keep track of all appointments. o CTI Plan ■ Make note of any goals family would like to add to their CTI plan FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE ■ Explain to the family the program expectations and importance of regular communication with CM • Cell phone (call or text) • Office direct line • Email O Review Schedule of Rent Payment (SORP) with family ■ During this time CM will inform the family of projected program end date and what the family is financially responsible for towards monthly rent and/or utility payments O If there are missing documents be sure to have those documents present for completion during this initial meeting ■ This includes missing supporting documents and missing information or signatures O Food Pantry Form ■ Review with family the food pantry policy ■ Make family aware that they can access food once a week ■ All forms must be filled out and submitted by 9am Monday morning for pick up Tuesday through Thursday ■ Inform family to communicate with CM on any special requests that are not regularly available in the food pantry • Diapers in larger sizes • Food allergies • In some cases gift cards may be made available to purchase such items o If gift card is provided to client CM will make a copy of gift card and have client sign and date the copy ■ Copy is then filed in CM section of client file Family meeting • CM is required to meet with family in person at least once a month O Depending on family need, program length and barriers CM may need to meet with family weekly O CM will maintain communication with family outside of the scheduled monthly family meeting as needed • During monthly meeting CM will review family progress with initially established areas of focus • CM is responsible for addressing any new barriers presented at family meeting or via various methods of communication • Family will provide CM with; O Monthly budget O Current paystubs FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE O Rent if appropriate (Interim Transitional Housing Families) • Money in cash cannot be accepted offsite O Utility payments (Interim Transitional Housing Families) • Utility payments are due two weeks after CM provides family with copy of utility bills • Utility payments are rounded to the nearest dollar amount and family is notified of the total amount due o Any other verification documents that CM has requested FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE Services for Families Housing Family Services Food Pantry for Housing Clients • Families in the housing program will have access to the pantry weekly • They will submit a request form by Monday 9 am • The family will then pick up the food anytime between 9-Spm Tuesday, Wednesday, Thursday • The family can request up to 10 categories on list and the quantity of each item as needed for that week • Volunteers in the pantry will fill the order and store on an assigned rack with the family's last name and quantity of bags(total) o From time to time, the case manager may need to fulfill the request if there is a late or last minute request • Families in the housing program go directly to the food pantry for pickup and do not need to check in at the front desk Food Pantry for the Public • Families Forward offers access to the food pantry to qualifying families once a month (every 30 days) that are not in the Housing Program • Families must reside in the following cities to qualify: o Irvine, Newport Beach, Tustin, Lake Forest, Mission Viejo, Aliso Viejo, Laguna Hills, Laguna Niguel, Rancho Santa Margarita, Dana Point and all other South Orange County cities, • Families need to fill out a registration form, provide photo 1D, proof of residency, and proof of income; documents will be updated annually • An appointment must be made in order to pick up food • Families will check in with the front desk before going to the food pantry if they need to update and documents, Child Care • There are certain grants that can assist with child care costs o Check with HPM for approval • They may be referred to Children's Home Society or the Department of Education for subsidized childcare programs Gift Cards • Gifts cards can be issued to families in emergency situations • There are gift cards for gas, groceries, target(clothes/shoes for kids) • There are $800 allocated to each family for emergencies such as car repairs, field trip cost for kids, or gift cards (some examples) o This an example of when check requests are submitted and a check is given to a family once the request is approved FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE • If a gift card is given, the case manager must write the amount of the card and the date given to the client on a ledger • CM to enter the gift card information in both the Client Track and HMIS systems • A copy must be made of the gift card which the family will sign and date. This copy will be added to their hard file Career Services • After the family meeting and a CT[ plan is created the case manager may refer individuals from the family to a career coach • The CM will give the contact information for career coaches to the client • The Career Coach will assist those that are unemployed or under employed and evaluate their work history and earning potential • Once an appointment is set up career will have a one on one appointment with the client; assignments will be given and this will continue on for the duration of the program • The Career Coach will: O Construct a new resume for client o Target the resume to fit each job description o Assist clients in obtaining professional clothing o Teach client to upload resume to various career sites o Give tips on how to interview for a job • There are a series of workshops lead by the Career Coaches, which are free to both the housing families and the public Community Cares • Families who do not have access to medical services can be linked to a provider • In many medical emergency situations families can be linked to services through the Prevention Program Manager o The Prevention Program Manager (PPM) will contact a doctor from her list of providers who will see a patient free of charge • The Community Resources Coordinator (CRC)can also assist families with enrollment to insurance(Covered California) , medical services, and food stamps • The PPM and CRC also put together a Community Resource Fair that is open to the public o This is an annual event hosted by Families Forward o Over SO service providers in the OC offer free health screenings, legal advice, financial counseling, workshops and kid's activities O It is located at Irvine Valley Community College O Everyone is welcome with NO need to enroll DIGNITY • EMPOWERMENT • HOPE Counseling Services • Families that are enrolled in the housing program are eligible for counseling if they chose to participate o Some counselors can meet with minor -aged children of the family o Meetings are set by appointment and meet at least once a week while they are in the program Community Counseling Center • Families Forward also has a Community Counseling Center available to the public o These services are offered to families with minor -aged kids o Families will call and make an appointment between Monday - Thursday from 9am-Spur o There is a fee that is based on a sliding scale Community Resources Transportation Services • Families that do not have access to a car are eligible for transportation services through the JARC, which is offered by Jewish Federation and Family Services • Through JARC an adult family member can make an appointment for a ride to and from an interview or any employment related meeting or appointment o A case manager will give the family member a referral to complete o It is then faxed over to Jewish Federation and Family Services for documentation • The family is also given ride vouchers; the family member is responsible to make the appointment for a ride ahead of time Vision Services • When a family member from the program has poor vison, they can be referred through our Gift of Sight program for glasses or contacts • This is a service free of charge to that individual • There are multiple locations for this service, but there may be a wait list • In order to proceed a: o Letter must be faxed o Appointment made • Copy of letter given to client Emergency Hotel Stay • When a family is matched to the program, but there is an issue in finding immediate housing for them at that moment, the family can be placed at a motel in the meantime until housing is ready for move -in FAMILIES FORWARD DIGNITY - EMPOWERMENT • HOPE • Families. Forward partners with the motel Keys Inn in Tustin, CA • If it is deemed necessary then a family will be referred by the case manager to the Keys Inn for a pre -determined time and paid for by Families Forward • The information will be faxed to the Keys Inn before the family's arrival and can check in with motel staff Seasonal Programs • Families Forward puts together seasonal programs to assist families • There are 4 programs that are offered every year: o Community Resource Fair- an annual event that brings over 50 service providers for free health screenings, legal advice, financial counseling, workshops and kid's activities to families o Back to School Backpacks- Backpacks are given for free to kids K-12 before the school year starts. Families who previously received backpacks within the past year will receive refill supplies o Thanksgiving- Baskets of food that are needed to prepare a Thanksgiving meal are given to the families; the food given out is based on a lottery which will depend on the donations received O Adopt -a -family -Holiday Gift Program- Donors give gifts to an assigned family based on a lottery; families must sign up for this program in October of each year Furniture • Families Forward receives various types of donated furniture • These donations are mainly used to furnish the homes for transitional housing • Some families that move into Rapid Re -Housing move in with no furniture at all • A request can be made to the Property Manager to see if there are extra donations to accommodate the family's housing needs O An email is sent to the property coordinator with furniture and/or household item request form attached o The Property Manager will confirm if the request can be filled • If it can be filled then the furniture will be brought to Families Forward and the family can arrange for pickup • Depending on availability, Families Forward has a partnership with Two Men and a Truck, a moving company that offers moving services pro-bono to families in the Rapid Re -Housing program c CM to submit a request no later than Tuesday of the week they want to utilize the service ■ Include Name, phone number, address, pickup time and list of items FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE File Management Creating New Family File • Before creating the file make sure all HMIS enrollment forms and program documents provided are completely filled out and up to date o Note all areas where information is missing to request from client during the next in person meeting • Case manager will use the P-Touch to create the following labels o Client name • Last Name, First Name • If there are two adults in the family only add the Head of Household to label o Tab I- Personal O Tab II- Financial o Tab III- Rapid Rehousing o Tab IV- Interim O Tab V- Case Management o Tab VI- Program • Use HP File Index as a guide for proper placement of documents within file Maintaining Record Keeping • It is required for the following documents to be filled/collected regularly; o Budgets o Paystubs o Home inspection forms o Gift card verifications o Rent receipts • Copies of receipts for Rapid Re -housing clients will be filed under Tab V- Housing ■ Rent receipts for Interim Housing will be kept by the Operations Associate ■ HRS will provide CM with a monthly ledger or what has or has not been paid by the client o Food pantry lists o Correspondence with client ■ Pertinent information that would affect their housing program • Change in child support income letter, court letters, cash aide award letters, etc. • Data Entry Clerk will perform audit on any new files on a weekly basis o Any corrections will be flagged with an attached explanation as needed HOUSING PROGRAM FILE INDEX CLIENT TRACK ID; HMIS ID: TH/IH RRH Grant Tab I — Personal Tab 11 - Financial ❑ ❑ HP File Index ❑ ❑ Income calculation worksheet ❑ ❑ Homeless Certification ❑ ❑ Entry Income Verification ❑ ❑ Y" party verification of homelessness ❑ ❑ Income Guidelines. ❑ FF Motel Reservation forms (If applicable) ❑ ❑ HMIS Enrollment Forms Divider ❑ ❑ CFC Client Forms (only if client is CFC funded) ❑ ❑ Current income Verification ❑ ❑ HMIS Consent Form ❑ ❑ Monthly Budgets ❑ ❑ Self -Declaration of income Divider ❑ ❑ Self- Declaration of Financial Resources ❑ ❑ HMIS Report (If applicable) ❑ ❑ Bank Statements-3 months ❑ ❑ Request for Services Form ❑ ❑ CES Referral ❑ ❑ Picture ID ❑ ❑ Social Security Card ❑ ❑ Immunization Card (0-5 years) ❑ ❑ School Enrollment Verification (5+ years) ❑ ❑ Birth Certificates -all house hold members ❑ ❑ Medical Insurance Cards ❑ ❑ Court/Custody Documentation (If applicable) ❑ ❑ Disability Documentation (If applicable) ❑ Exit Documents HMIS forms, CFC survey (If applicable) Tab III — Rapid Rehousing Tab IV — Interim ❑ ❑ Schedule of Rent Payments ❑ ❑ Current Lease Agreement ❑ ❑ Lease ❑ ❑ Residential Rent ❑ ❑ Check Requests ❑ ❑ Exhibit A ❑ ❑ Rent Receipts ❑ ❑ Rental Formula ❑ ❑ Key Exchange Agreement ❑ ❑ Drug Test ❑ ❑ Rapid Re -Housing Needs Assessment ❑ ❑ Misconduct Act ❑ ❑ ESG Lead Screening Worksheet ❑ ❑ Housing Inspection Forms (If applicable) ❑ ❑ Rent Reasonableness Checklist and Certification ❑ ❑ 30-Day Notice/Extension ❑ ❑ Minimum Standards for Permanent Housing ❑ ❑ Security Deposit Return ❑ ❑ Housing Inspection Forms (If applicable) Tab V—Case Management Tab VI - Program ❑ ❑ CT[ Plan Both Programs ❑ ❑ Client Email Correspondence ❑ ❑ Program Offer Letter ❑ ❑ Crisis Documentation (If applicable) ❑ ❑ Termination of Assistance Policy ❑ ❑ Signed gift card copies (If applicable) ❑ ❑ Termination of Housing Process of Appeals ❑ ❑ Filled food pantry forms (If applicable) ❑ ❑ Communication Disclosure ❑ ❑ Program Contract ❑ ❑ Grievance Policy ❑ ❑ Consent to Exchange Information ❑ ❑ Consent for Services ❑ ❑ Tenant Screening Form (If applicable) ❑ ❑ Credit Report ❑ ❑ Background Check Disclosure ❑ ❑ Printed background check 4 ❑ ❑ Employment Agreement (If applicable) CASE MANAGER NAME: FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOP - Case Manaciement Best Practi ❑ Meet at least once a month in person c Review CTI plan o Discuss family progress towards areas of focus c Discuss barriers (new or existing) Refer family to appropriate resources o For "pending" clients, discuss progress on housing search and employment status if unemployed ❑ Collect previous months budget o During monthly meeting review client's budget in detail o Refer family to Financial Literacy if needed ❑ Collect rent receipt O For RRH By the 3rd of the month O For TH/INT on or before the 1st of the month ❑ Send out utility bills (TH/INT) O Collect utility bill payment O 2 weeks from when CM sent out payment o Amount due for utilities: $ ❑ Collect previous months paystubs ❑ Send out check requests for FF rent portion (RRH) c No later than the 31d Monday of each month FAMILIES FORWARD DIGNITY - EMPOWERMENT • HOPE Case Management Deadlines Check Requests e Rent Check Request (Rapid Re -Housing) o Rent check requests are due on or before the third Monday of the month o Check Request Deadline o Check requests must be submitted by 11AM every Wednesday • When client makes a request that will result in cutting a check CM must get the expense approved by management team o At this time you may make client aware if the expense was approved or denied • Check requests are completed for the following items O Rent for Rapid Re -Housing families o Childcare assistance O Car repair assistance O Security deposit reimbursement o Any other expenses that have been approved d When completing check requests make sure all fields are included which include: O Urgent request (if applicable) O Date check request is completed O Amount O Check payable to: O Address (of vendor) O CM name (requested by) O Indicate new or repeat vendor • If new vendor a W-9 must be attached to request and saved to the "G" Drive O CM will always mark "return to requester" ■ CM must always have a copy of the check and check request to file o Purpose O Month O Grant O Client name O Current client address O At this point CM will make a copy of the check request O First approval signature O Second approval signature (if amount is $1,000 or over) ■ See sample check request attached Once check request is complete submit to accounting When check has been given to CM make a copy of the check o Place check request copy with copy of check in client file Interim Housing Deadlines • CM -Case Manager; HRS-Housing Resource Specialist; FM -Facilities Manager; FA -Facilities Assistant; OA-Operations Associate FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE WHEN WHAT WHO Move In Family is given all keys (mailbox, home, garage) and CM, OA introduced to new home. 3 — 5 business Once the family has moved in (physically occupying the unit) OA days after the Home Orientation is conducted within 3-5 business move in days, At this time Tenant Education, Move -In Inspection, and Affordable Housing List is given. First Tuesday Monthly Home Visits are conducted the first Tuesday of FM, OA of every every month for the entire program period month 1 week after If family does not pass Home Visit the recheck is conducted OA, CM if home visit the following Tuesday. Allowing one week for the family to available rectify the problem. During If there is an emergency maintenance problem (affects FM Tenancy habitability — relating to sanitation, water, heat, etc.) family is instructed to call Facilities Manager During If there is a non -emergency maintenance problem family is FM Tenancy instructed to e-mail Facilities Manager. During Facilities Manager will attempt to fix in-house and will FM Tenancy schedule outside service if needed. During All maintenance follow up with tenant is conducted by FM Tenancy Facilities Manager in a timely manner. During When HOA complaints are received pertaining to client, the CM, HRS Tenancy issue is corrected and follow up is written to HOA. The Template can be found on the G drive —G:\Forms\Program Forms\Transitional Housing Forms\Property Management. During When HOA complaints are received pertaining to HRS Tenancy maintenance/non-client, the issue is corrected and follow up is written to HOA 30 days Notice to vacate is given to family and PM team' CM before move out FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE 7-14 days Final home visit is conducted. Move out inspection is CM, OA, FM before move scheduled with client out 7-14 days The Move -Out inspection is completed with tenant to CM, OA, FM before move discuss potential Security Deposit deductions and move out out checklist. The tenant is to provide CM with furniture request at this time. Any permissible furniture to be taken with tenant will be written on their move out inspection form. ASAP Any exceptions of lease extensions given to client must be CM shared with PM team as soon as possible. Day of Move Key exchanged is performed at the home face to face on the CM, OA Out family's last day. Wall<through should be done by CM at this time. If unit is not acceptable CM is to work with client to resolve issues. If family is not ready, key should not be exchanged. Within 3 days First inspection is completed to evaluate any damages or FM post move excessive wear and tear to be deducted from Sec. Deposit out Within 21 Security Deposit is returned to family within 21 days of FM, CM, OA days post move out. Only damage to the unit, cleaning fees and/or move out utility fees may be deducted from the security deposit. 1-2 weeks Home is evaluated for fix -its, furniture replacement and first FM, FA post move clean sweep. Maintenance is scheduled and conducted. out Facilities Manager conducts final Maintenance Walkthrough with Maintenance Checklist for property file —Also leave two light bulbs and one 9V battery per unit. 1-2 weeks Professional cleaners are scheduled for full cleaning FM post move out 1-2 weeks Painters are scheduled if necessary FM post move out FAMILIES FORWARD DIGNITY - EMPOWERMENT • HOPE 1-2 weeks Carpet cleaner scheduled FM post move out ASAP Family Profile is given to PM team as soon as available even CM if not finalized Once FP is Warehouse and home are evaluated to match Family FM, FA received (2-3 Profile. Items are pulled and unit is adjusted to family weeks post profile. One corkboard per child's room is supplied. move out) ASAP If Family Profile changes adjustments to unit are made CM, OA, FM, FA accordingly. I ASAP Counselors are notified that the unit is ready to go. HRS, OA 3 days before Notification to PM team of new family moving in at least 3 CM move in days prior to their move in >1 week post If unit sits fora period of time (over two weeks) spiffing is OA Group Visit necessary for dust build-upjust prior to family moving in ASAP Throughout entire process make sure the Whiteboard is T OA updated so that all units have the most current information Family Moves in and the process re -starts! Data Deadlines • New family data o All families need to be entered into HMIS and Client Track (CT) within three days of receiving case assignment which is the "Match" date from the Coordinated Entry Systems (CES) • Services o All services need to be entered into CT and HMIS within three days of rendered service date • Exiting Families Upon Completion of Program o All families need to be exited from HMIS and CT within 3 days from move -out date • Case Notes c Case notes need to be entered no more than three days after family meeting FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE ■ Case notes are required for the following; • Entry of the family into housing case note • First family meeting case note • Family meeting case note for each month in the program • Gift card services provided • Emergency with client, family or home (entered immediately) • Information or interaction CM feels important to document • Exit case note FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE Familv Move -Out Process Interim Transitional Housing; Exit Meeting/Phase 3 • CM to schedule exit meeting with client within the last month of their program • During meeting CM and client to review progress on: 0 3 areas of focus o Support systems o If utilizing the Rapid Re -Housing program, review SORP and program expectations • CM to provide client with Exit packets for each member of the household • CM to collect income documentation and budget for the final month Move -out Inspection/Key Exchange • CM to provide client with appropriate notice before expected exit date 0 30 Day Notice given for an extension that is at least 30 days o An Extension of Termination Date form is given out when an extension is less than 30 days ex: 1 week, 2 weeks • CM sends Interim move -out inspection request to Housing Resource Specialist (HRS) via google doc and calendar invite to schedule date and time c Move -out inspections are conducted 7-14 days before exit date o During inspection, HRS will note any repairs that need to be made • If needed, client to submit furniture and household item request to CM o Request can be made before or after move into permanent housing o If needed, CM can connect client to free moving services • CM to submit request to HPM for assistance from Two Men and a Truck ■ Two Men and a Truck can only accommodate moving request once a week on Wednesdays; request deadline is the Friday before ■ Two Men and a Truck can only move furniture from Families Forward to the client's home; they cannot move furniture from any other locations • CM to perform key exchange on the day of move out o CM to do a final walk through of the unit prior to key exchange and note any concerns if necessary o If family is not ready to move out, then do not exchange keys with client and consult with HPM • Once family has moved out, Operations Associate will provide security deposit form to CM o Any unpaid utility bills and/or damages made to the unit will be deducted from the security deposit o Client cannot use security deposit towards any unpaid rent o Any monies left over, will be given back to the client in the form of a check FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE ■ CM to submit check request to accounting with security deposit attached ■ Check can be mailed out or picked up by client ■ CM to inform client that the process can take up to 21 days Rapid Re -Housing; Exit MeetingZPhase 3 • CM to schedule exit meeting with client within the last month of their program • During meeting CM and client to review progress on: 0 3 areas of focus o Support systems o Rent expectations for the remainder of lease • CM to provide client with Exit packets for each member of the household • CM to collect income documentation, rent receipt and budget for the final month Data Exit • CM to email Exit Request to Data Entry Clerk (DEC) at least 2 weeks prior to client exit c CM to CC Data Quality Manager and Housing Program Manager in email • CM must provide DEC with completed exit packet o Client must mark each question, sign each packet for each member of the household o CM to review the completed exit packet before submitting to DEC o Incomplete exit forms will be entered as "no exit interview completed" FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE Regular Case Manager Meetings Individual Supervision • This meeting takes place weekly with HPM • HPM will send CM a re -occurring individual supervision meeting invite via Outlook • During this meeting CM will type up a list of their caseload with any updates on each family to HPM • This meeting serves as additional accountability and support for CM Case Management: • This meeting takes place every Monday at 3:00pm • All clients that will be presented during this meeting must be submitted the Friday before the meeting to HPM • During this meeting the following will be presented by CM: O New families that have moved into housing, RRH or TH • CM will give brief description of family background, go over areas of focus established for CTI plan, and projected program time frame o Client updates • If there is any new information on active or pending clients that may impact family, program or involvement with other staff members an update will be made during this time • For example, client obtained employment, serious health issues, transportation changes etc O New Pending Clients ■ HRS will introduce any new pending clients for the week and give a brief description on the family o Family Exits ■ If presenting on family exit CM will discuss the areas of focus that were accomplished during the program and those that were not ■ Management team may have questions in regards to outcomes, such as family destination after program Property Management • This meeting is conducted monthly on the 31d Monday of every month at 2:30pm • The Property Management meeting is specifically for Transitional Housing as well as any housing inquiries for furniture requests • This monthly meeting is to discuss turn over, vacancies, upcoming exits, unit problems, procedures etc FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE Staff Meeting • This meeting is held once a month on the first Monday of the month at 9:00am-10:30am • A staff member from the operations team will email meeting agenda the week prior to meeting. • If you will be in charge of speaking on any particular topic during the meeting your supervisor will let you know in advance Program Committee Meeting • This meeting is held once a month on the 2nd Tuesday of the month at 8:00am-9:00am • A Program staff member will be assigned to email meeting agenda the week prior to meeting, o Each month a different program staff member will be responsible for creating agenda, prepping board room, taking attendance and minutes during meeting, and lastly writing up final draft of minutes and emailing them out to program committee • Agenda items are obtained from Director Housing Programs and Services the week prior to meeting Families Forward Exhibit B Documentation, Recordkeeping, Reporting and Monitoring Requirements FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE Enrollment Process: m Once CM receives match, CM will call client within 24-48 hours to schedule appointment for Packet Review and Tenant Screening with CM and HRS • Appointment takes approximately 2 hours to complete ■ CM to send calendar and google doc invite to HRS for date and time of appointment o Client to bring the required family documents: ■ Proof of Income (one month's worth; last 3 paystubs) • Birth certificates • ID's for adults • Social security cards ■ Immunization records for children 0-5 or school enrollment verification for children 5+ • Medical cards • Current pay stubs or any other income source • Bank statements • Car registration and insurance ■ Custody/court documentation (if applicable) • Disability forms (If applicable) • Include Dara Entry Clerk to calendar invite (availability to attend appointment based on DEC capacity) o DEC will make copies of all family documents during appointment e Begin Enrollment Process (Packet Review and Tenant Screening): c CM to start meeting with review of homeless certification from CES ■ CM to gather current documentation from client • CM to provide Homeless Certification form for client to sign and date, as well as provide the homeless documentation from agency, emergency shelter, church and/or social service agency • If client is stating the family is sleeping in their vehicle, CM will complete a vehicle inspection in the FF parking lot. CM will sign Homelessness Certification verifying homelessness FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE o Once the documentation is collected, CM will proceed with the Packet Review o For any family that does not re -certify and/or cannot provide the above information, will be sent back to CES ■ CM to update HIC with this information ■ HIC will send update to CES on a weekly basis o CM will gather all family documents and hand over to DEC o HRS will conduct Tenant Screening in which housing history and credit report will be reviewed o For packet review, CM will fill out an enrollment packet for each member of the household ■ CM to use this time to ask about family and homeless history CM will also review and verify income documentation provided by client. Adults earning any form of income must sign the Self Declaration of Income and provide any of the following forms of verification that are applicable: ■ Last 3 paystubs for earned income ■ If paystubs are not available, then an offer letter as it relates to a new job, that has not yet started, can be submitted ■ An award letter on letterhead for Cashaid, Disability and/or SSI ■ Court paperwork as it relates to child support or alimony ■ If the above mentioned documents are unavailable and CM has done their due diligence in trying to obtain documents (as noted in emails and/or case notes) CM will use the Self Declaration of Income as proof of income for the family o CM will plug in this information into the Income Calculation Worksheet to determine if family meets income guideline requirements o Based on the information, circle the income bracket the family falls under on the annual HUD guidelines document ■ CDBG participants must fall under extremely low to low-income bracket o Once packets are completed, CM will explain and obtain client(s) signature on all program documents during appointment FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE Q Complete Enrollment Process o CM will submit the completed HMIS packets and family documents to DEC to enter information in both HMIS and Client Track Systems o CM will receive client information from Data Entry Clerk (DEC) after client information is entered into both Client Track and HMIS systems ■ DEC will provide information to CM within 24 hours CM will pull an HMIS report and Background Check on all adults in the household O Note: o What program is the family entering (interim Transitional Housing- I- TH or Rapid Re -housing)? ■ All I-TH clients are required to complete a drug screen prior to program entry as part of a needs assessment and not as a determinant of program entry ■ CM provides a referral to all of the adults in the household to complete a drug screening at a predesignated location 6 Clients must complete the Packet Review and Tenant Screening in order to complete enrollment into the housing program ® Active vs Pending Clients o Once the enrollment process is completed, CM will maintain a caseload consisting of both Active and Pending clients ■ Active clients- homeless families that are currently in Interim Transitional Housing or Rapid Re -Housing Programs ■ Pending clients- homeless families that have been matched to Families Forward and have completed the enrollment process, but have yet to identify permanent housing • CM and HRS must check in weekly with family until housing is identified • Family will be sent back to CES for non-compliance with program rules or ceases communication with CM FAMILIES FORWARD DIGNITY • EMPOWERMENT - HOPE Family Move in Process Interim Transitional Housing: • Prior to all move -ins, the client must be given a drug screening referral and submit for a background check o Review results with Housing Program Manager • CM sends Interim move -in request to Housing Resource Specialist (HRS) via google doc and calendar invite to schedule date and time • Property Coordinator will meet with the family to review lease agreement o The family's rent amount will be calculated using the Rental Formula form with the included chart below Tier Rent Monthly Household Income 0 $100 Below $850 1 $200 $851- $1500 2 1 $300 $1501- $2500 3 1 $500 Above $2501 o Rent will not exceed 30% of client's gross income as stated in ■ Proof of income ■ Client self -declaration of income ■ Or signed intake form o A $500 deposit is required for move -in into interim housing o During this time CM can prepare food/toiletry bags for family • CM will lead second half of lease signing meeting: o CM will go over program expectations/guidelines/agreements • During this meeting CM will go over the following documents: o Termination of assistance process of policy a Termination of housing assistance process of appeals a Transitional housing application process o Misconduct act o Exhibit A o Program contract o Rent Amendment o Community cares forms • Give copies of documents to client • Give client directions and address to Interim Transitional Housing unit o Families Forward staff will go in pairs to escort the family to the unit o Family will follow you in their own vehicle to the home o Prior approval is needed if CM plans on having the family in their personal vehicle • Take family on a tour of the home • Before leaving the home let family know you will be in contact with them in the next 2 days to make their first family meeting appointment v FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE Rapid Re -Housing: • Client and/or landlord to send over W9 and copy of unsigned lease/move-in statement to CM • CM to evaluate/ create Schedule of Rent Payment (SORP) • CM to submit check request to accounting with copy of unsigned lease/move- in, W9 and SORP o Check requests are process every Wednesday ■ Only emergency check requests will be processed outside of that time frame o Check requests that are over $1000 need two signatures from a Director and/or Manager o Check requests that are under $1000 need only one signature from a Director and/or Manager • Request copy of signed lease as soon as its available from client or landlord o Get this from apartment community or client o Save signed lease copy in the "G Drive" • Apartment community will be sent copies of below documents by CM: o Communication disclosure o Program contract o Apartment Inspection o SORP • Set up 1st family meeting • Set up home orientation with Housing Resource Specialist o Client is responsible for setting up this appointment o CM is responsible for giving client contact information for Housing Resource Specialist CRITICAL TIME INTERVENTION (CTI) Critical Time Intervention (CTI) is a time -limited evidenced -based practice that mobilizes support for society's most vulnerable individuals during periods of transition. It facilitates community integration and continuity of care by ensuring that a person has enduring ties to the community and support systems during these critical periods. CTI • A well -researched and cost effective Evidenced Based Practice proven to assist with transitions • A specialized intervention provided at a "critical time" (typically from institutional to community care) • Connects people with formal and informal community supports • Is a time limited (typically 9 mos), divided into 3 phases • Focuses on a limited number service areas that promote successful transition CTI Worker Role • Finding and maintaining successful linkages vs providing a lot of direct services to the client • Service plans are not comprehensive and focus on making the transition successful • Actions are related to the phase a person is in --- C-T-I-worker`s-role-is--well-defined= what -the -worker -does AND -what -the worker does not do because focused on gradually reducing intensity of services CTI Worker Tasks • Care Management (CTI informed) • Attend team supervision meeting and offer peer supervision • Support other CTI workers • Report on whereabouts dally InINSTITUTE f'rrm��frzg fxrullen..o (rz Ifen![h R !lw.an S.n9.cn THE THREE PHASES OF CTI PHASE I: TRANSITION TO THE COMMUNITY Begins the day of discharge. (There may be a "pre-CTI" period) Worker's role: • Engage client • Develop treatment plan based on some 6 treatment areas • Meet with community caregivers • Begin connecting to resources and services for areas of focus • Assess potential long term support systems & provide direct services as needed This is the most intense period of CTI where the bulk of the work is; engaging the client, addressing crises, assessing for potential long term support systems, beginning linking with caregivers PHASE II: TRY -OUT Meet less frequent Worker's role: • Adjust the systems of support for the client • Monitor the effectiveness of the support setup and intervening when • Evaluate progress with areas of focus and connections to those areas The Try -Out phase is all about adjusting the systems of support for the client and trying to locate the gaps in services that need further adjustment. Often involves negotiation and mediation PHASE III: TRANSFER OF CARE The final phase of CTI focuses on completing the transfer of care to the community resources that will provide long term support to the consumer. Preliminary work leading up to the transfer of care has been done throughout the previous phases Worker's role: • Fine tune the systems that have been established • Finalize long term supports and connections made to areas of focus • Transfer of care (includes an official meeting client and all primary supports) • Terminate from client (includes a final meeting) off INSTlTU7E 11 R.f(:m Ifrohh�A�fvia6n tielv(eCe PHASE DATE FORM The form is used as a tracking devise to see, at a glance, the phases any particular service recipient is in. Because of the "no drop out" policy, individuals who pass away, refuse services or disappear should be indicated. Date of death should be recorded. For persons who refuse or disappear, document dates separately as problems often resolve with time. If not, indicate date of the refusal or disappear date. The CTI case manager should take the latest updated copy of form whenever he/she goes into the field. For serves as a reminder to the CTI case manager of upcoming transitions, and helps monitor that they write phase plans on time. This form does not go in the chart. It is updated by the field coordinator and is copied for everyone and handed out in supervision meeting. The supervisor has it next to him for reference. PHASE DATE FORM INSTRUCTIONS CTI Case Manager: Takes latest updated copy of form whenever you go into the field. Fieldwork Coordinator: The following are instructions for F.C.: • keeps form updated • makes copies for CTI case managers • brings to all team meetings for reference during case review ■ reminds CTI case managers of upcoming transitions • monitors that they write phase plans on time. IIINS71TUTE rlolnOmw P—Ik:a to rreann a Mu��n.�,w�vU.c. PHASE TREATMENT PLAN The Phase Treatment Plan form is used to make a treatment plan for each phase based on an assessment by the worker. Assessment is not a one-time event. It is a process that continues as needs change. An assessment precedes each Treatment Plan. By phase 2, the rationale for the treatment plan is based on in vivo assessment from phase 1 and success of goals from phase I. Phase Treatment Plan is completed 2 weeks before entering a phase. The first step of phase 2 treatment plan is to summarize where have gotten to by the end of phase I. Treatment plans should be person -centered and attainable given the time restraints. It is essential that the worker not impose his or her own aspirations for the person in the treatment plan. However, goal setting should be done in a collaborative manner with shared decision -making between the staff person and the service recipient prioritizing the person's problems together and agreeing on a strategy to address them. Not all goals can accomplished in the phase and some may need to be put on backburner. No more than 3 areas of treatment should be documented and pursued. The rationale should always be tied to the phenomenon the worker and service recipient are trying to avoid (e.g. return to homelessness, limit drug use, etc.). At the bottom of the form, the "update on area" should be a brief accounting of where the individual worker feel the person is at regarding the goal. This should be as a result from meeting with the person two weeks before the end of the phase. At the end of the third phase, rather than placing a note in the "update on area", the worker should instead write up a detailed summary/case-closeout in a progress note CTI PHASE TREATMENT PLAN INSTRUCTIONS Phase treatment plan is completed 2 weeks before entering a phase — conduct assessment and pick area(s) of focus for that phase. The Phase Treatment Plan form for each phase should include: ■ areas of focus reasons for choosing that area ® goals for that area 19 INSTITUTE tTrrnefrrq F,arllrn.n In f/ml[A w 9fvmnn.�'ernrn. PROGRESS NOTES The progress note is used to document all contacts including collaterals in the community, informal supports and with the service recipient. Since the bulk of the work is done in the field, notes are typically written in the field and should always carry blank notes with them [hint: using 3 hold punched notes make it easy for ensuring notes get into folders]. Essential to list who they speak to including name, agency, title, contact information and location of meeting. CTI worker should avoid documenting "met with case manager from ZZZ program". Each contact should have its own progress note (e.g. a face-to-face meeting and a telephone conversation about/for/with the same service recipient on the same day would have two progress notes) Although progress notes are used throughout all phases, they should reflect a decrease in the intensity of services as people move from one phase to another. Field work coordinator should monitor progress notes to ensure consistency and timely. If notes are not being filled out properly or linkages are not being made, this should be discussed in field coordinator meeting and if necessary supervision meeti ng. PROGRESS NOTE INSTRUCTIONS Each progress note represents a communication or a conversation with a linkage and should include: • communication between CTI worker and service recipient [e.g, visited, sent letter to a sister, service recipient called me, etc...] ■ an indication if this is a formal or informal support for the person (check all that apply) • person and relationship to service recipient, and type of activity (e.g., if it is a meeting, or if it is an attempted visit) • the treatment area related to the note ■ how CTI worker helped person establish connections or strengthen community supports ■ how CTI worker monitors linkages and transfers care to the community INSTITUTE riante+w iiumm�5�'vlcel CTI Phase Treatment Plan Date met with client to complete treatment plan: _ / _ / Client Name: MM DO YYYY Phase #: Phase 1 Phase 2 ❑ Phase 3 ❑ *Date phase starts: _ / _ / Due date for end of phase: MM DD YYYY MM DO YYYY CHECK THE AREAS FOR THIS PHASE: (CHOOSE> T03AREAS) Counseling and Psychiatric Treatment El Housing Crisis Prevention & Management Career Coaching F } Money Management Substance Abuse Treatment ❑ Family Intervention Area #1 Reason for choosing this area: Overall goal for this area: Area #2 Reason for choosing this area: Overall goal for this area: Area #3 Reason for choosing this area: Overall goal for this area: Update on areas FILL CUT AT END OF PHASES ONE AND TWO ONLY. AT END OF PHASE THREE, WRITE A CLOSING PROGRESS NOTE INSTEAD, WHICH DESCRIBES WHOLE INTER'/EIV770N.) * This date must match `actual' date on Phase Date Form. CLIENT SIGNATURE CT -I WORKER SIGNATURE MM DD YYYY _! _! MM DD YYYY CZarvirac (IJ https�!/app.dienttracknev'to:3.Lr.fau,pagr..nsp,;[nlineralsc � hnpsaTapp,dicnmack.neV2Ui3.1{Mampn9e•aspz?Inlfne•klw FAMILIES FORWARD DIGNITY • EMPOWERMENT a HOPE SerAce• .. Urra Ym w untie' URRVafry +. Toaf � Help.. Wirkdon e' w ......_.... ..__._.. .._.__._..._.... _...........................__..._ , ... . f. Dp ..____ _._700 137.00 ..-rRnYld _ •teMWAnPo Rdws s• .) 88ctpack R•fAI �C'•a-d • _ 1.00 07.00 N7m Rahkl ro MOl11U'�i o�Rdaei •; :7 C. Repair � DMlen 1.00 $0.00 sr&w RwblcI W MDUArlo RMusr. •� Domed Car �d T_, 1.00 90.00 faun ,_ _ .. . fWokt re M'WANo Rdwe ± Ma.4lpCortassWars. • Lea^_] 100 . faUO ia.0a Ras>kl to MOUANo Ralaasa L.,_:�--------- J sari w w pours .. _..........____.... .... ;Daw. :j .. 1.aD 10.00. fa.DD ._ ..... (^RremLroMCUANoRd....+[ J ugdy wposils DWua _ • 1.00 $0.00 10.m Rnokl to MOUnNO Rdwe •: IIn--FnvIMwN asdsUnce .aIon Ddlal. • t 1 m .. f5000 . i SOm ;Reatrct b fg11ANo Rd.ra •' 7 Hvu Vwa I�a1 .n__,f 1.00 $60.00 S50AD -111 t. MUUXNo Re eica i ►a*m Gift Cad _-� DaOan 1.OD f16m flSm :ReslM tofWUANo Ralw�.-. . t]C.rea3ertim 3 praerfw<hOg �Odlaa--_' 1.00 f6000 $50.00 ��WMC(1lMdo Ragxev �I carsv Assezprmnt e (Hau_J. 100 f60.00 fw.aa Rw,aid ro elquryA. Rdaw .•J (-_.-'--"------__--- 7 Gmrfanma u7eswnestlw WartO .. .. Cwrt • .. 1m 1�aaa $HAD . 7oM(x114do R:laiw `i i cw.a smina PO iew apwa-up) rCoue !J 1.00 _ _ f50 DO f30M _._..__..._....__._._._.. ......... _ [RashutoMOWYAO Reties. •J ......__......._._. _� J Canersemav 7eckW5'p,gk Qu.s4onsl 1.00 S60DO f5040 (tlavlct�-��ANO Rdaasa a Cana Sams,ar laaY ircnaOi.s Far Succes4 .. .... GurA • ta0 650.00 f50m PacblGl MOUANp Rdaaa 3 Ca - iwuww lo0,w7 cwwi_._._. •i fA0 $5000 from (17wtriclb MCN1�(o tla w.. . O rooa wt ... . 7 Wee.ly faW LCaINa t0. 50.60 llsof _._......_.... �RaMd 1. MOUAn1. Rdays. •; FcW Vouches __�m . .. _._.....__ (OoAw.� �f 100 f0A0 •RaNk1b MOUAnIO Rahn _.__..-._-...-.-.-... a C) NMF Supp. prtf f. *. ID) ........... .... ,f0.00 ........ .. ... ... ._ 7 Caau[+r. Managem.m ._. _._• Od rw 1.00 MGM f30.m :RnrdabMDUANa rlelmee .'. Cpuns.hng.,,.,.. �OWlap _^.._• 1.00 f50.00 fW.00 bMOUANo Rahn._... .. ..__.... .... Otl Cud _.. ..... .. 1)ollen i 1.00 .... .._:Ra11a fa.W . IRsI dt MCU11NO Rehne • - :) ofller IOofela .) too ...... saoD w.aa �Rasindl MCRlAnOp Raleas--• rRD,oR.. ... _ . _.. __ 1 _m m 9 _. �..................... 7aaddq w�1ou u r Rdwe. _. am WAG Sam fits-& X_ca' e1 FAMILIES FORWARD DIGNITY • EMPOWERMENT e HOPE © http�Jiapp.crenrtrackneV20 tS :/Mlainpagv.a5{TaMbne=hlu ae agaa s�e�a _ Gamily Member: Ti _ Avrtrty Lmb 31l80.38 wane Enwamenll' �'07f1fi1701./,. Pe Id N:i1W _t ser.fae;' aVl Card Location: IFamIA.n FwwWN W� Da,A;• joviziuzpi<; units or m.— +? D-4- 'J K6.4 e Carol (7 Ho units • [—�i.aoj Total 625M us« e«!wmi+p Me service: ae Rfwra t] Arian: (� SELECT - _.__.__._._.- R""'Actbn Vlan: ELECT Co —ft _............. +..... um Awry' To a«X Ta fwr"v� Naw cdiole a enfat 6ekw. _— Raalnclion;• 'V Acura aMOU; Inb Aeknae fi:%Cwe Maoloem«1t • Services need to be entered into Client Track for the following: o Entry- The "Entry" service will be logged into CT upon client move -in o Case/Care Management- When logging this service CM will enter the amount of time spent with client ■ "Units" are the number of hours spent with client and the value will auto populate according to time entered ■ CM will enter "Case/Care Management" service for every client meeting o Childcare Assistance- CM will enter "Unit Value" which will be the dollar amount check request was submitted for and approved o Rental Assistance- Will be entered monthly, "Unit Value" will be the dollar amount check request was submitted for ■ Date for each service is as follows: • Month 1: move -in date • Month 2: ]It day of that month • Month 3: 1st day of that month, etc ■ this amount should reflect schedule of rent payment o Security Deposit- Upon client entry Families Forward will often times provide security assistance, "Unit Value" will be the dollar amount check request was submitted for ■ this amount should reflect schedule of rent payment FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE o Car Repair- CM will enter "Unit Value" which will be the dollar amount check request was submitted for and approved o Gift card- CM will enter "Unit" and "Unit Value" ■ "Unit" will be the number of gift cards given ■ "Unit Value" will be the dollar amount each gift card is worth ® If gift cards have different values they will need to be entered separately ■ "Total" will be auto populated according to the data that has been entered ■ Examples of gift cards are: Target, Grocery Stores, Walmart, Coffee shops, Yougurtland (all except Gas Cards and Buss Passes) ■ Once service is entered CM will "Edit" the service under the "Services" tab and add a comment detailing the specific store location or type of gift card that was provided, including total amount (refer to image 3) ■ Retrieval of gift cards will need to be approved by HPM o Gas Card- CM will enter "Unit" and "Unit Value" ■ "Unit" will be the number of gas cards given ■ "Unit Value" will be the dollar amount each gas card is worth ® If gas cards have different values they will need to be entered separately ■ "Total" will be auto populated according to the data that has been entered ■ Retrieval of gas cards will need to be approved by HPM o Home Visit- Housing Resource Administrator will provide completed Home Visit form with all pertinent details ■ CM is responsible for entering service monthly ■ Units and Unit Value will not need to be changed or entered c Weekly Food- CM is responsible for entering service weekly ■ Once filled food list forms will be returned to CM in their mailbox ■ Units and Unit Value will not need to be changed or entered o Other- Any items not detailed' in the Quick Services List will be added under the "Other" section ■ Some examples of these are: Buss passes or items purchased specifically for clients (Bikes, diapers, clothing...) FAMILIES FORWARD DIGNITY - EMPOWERMENT • HOPE Case Notes Entry Case Note • Clients moved in on (Date) • Current property: (Address) o Apartment community: (Name of Apartment Community) • Monthly rental amount for 2bd (3bd etc): (Actual dollar amount) o Families Forward assisted with (Dollar amount and specify is assistance was towards rental assistance, deposit or both) • Clients program is projected to be (Time frame) • Brief description of family: See sample below o Two parent house hold with one male child of age 9 that has been diagnosed with Autism, son is currently receiving services offsite. John Smith (father) is recently employed with gross monthly income of (Dollar amount), and Pocahontas Smith (Mother) is employed with gross monthly income of (Dollar amount). • Areas of focus for the family are (CTI Plan) First Meeting This Case Note will outline the CTI Plan (sample below) CM met with client Jane Smith and went over goals and expectations for the time the family is in the program. Client agreed and understood all of the following areas of focus and expectations: • Monthly budget will be kept by the family and reviewed during monthly case management meeting • Provide family budget to case manager on a monthly basis • Meet with case manager weekly and/or monthly • Rent receipts are due by the 3rd of each month (RRH) o For interim housing rent is due on or before the first of the month • Meet with career to obtain employment (if applies) 3 areas of focus and actions steps discussed: o Career- client to make an appointment with career coach within the next week • Housing client to check in weekly with HRS and attend the Tenant Education Workshop on 6/1/15 o Counseling- clients expressed interest in couple's counseling and will make an appointment within the next 2 weeks CM provided client with a $50.00 grocery card to obtain pots and pans. Families forward also gave family plates, cups and silverware. CM provided client with HRS contact information so that she could schedule home FAMILIES FORWARD DIGNITY - EMPOWERMENT - HOPE orientation and begin the process to get on waiting lists for affordable housing. CM went over SORP with client and client understood what she is responsible for towards her rent. CM will continue to monitor family progress. (End Sample) Family Meeting Include client's progress on areas of focus indicated on CTI Plan. You may include clients housing expectations. Include facts only. This may include but are not limited to documents obtained from client and reason for communication (ie. Follow up, re -certification and intake), method of contact ie. phone, face-to-face or email. You may include statements or quotes from client ie. Client stated he is having difficult time finding employment. [Space] You may include the appearance of the client, interpretation of client's behavior etc. Use words such as appear, seem etc. Assess challenges or barriers in obtaining housing or completing goals, [Space] State what the next plan of action will be. You may mention specific dates or times in which goals or follow-up is expected. Plan should reflect Family Plan. Re- Certification/Extension • Families within a month of their expected end date will be up for re- certification. At this point CM will review all goals and progress family has made and will either keep projected end date or request for an extension. Include client's progress on goals indicated on CTI Plan. You may include clients housing expectations. Include facts only. This may include but are not limited to documents obtained from client and reason for communication 0e. Follow up, re -certification and intake), method of contact ie. phone, face-to- face or email. You may include statements or quotes from client ie. Client stated he is having difficult time finding employment. [Space] You may include the appearance of the client, interpretation of client's behavior etc. Use words such as appear, seem etc. Assess challenges or barriers in obtaining housing or completing goals. [Space] State what the next plan of action will be. You may mention specific dates or times in which goals or follow-up is expected. Plan should reflect Family Plan. Incident Report CM will create a special notation in case note when there is an incident ie. Issues with their home, family emergency, loss of job, police involvement etc. FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE Include client's progress on goals indicated on Family Plan. You may include clients housing expectations. Include facts only. This may include but are not limited to documents obtained from client and reason for communication (ie. Follow up, re -certification and intake), method of contact ie. phone, face-to- face or email. You may include statements or quotes from client le. Client stated he is having difficult time finding employment. [Space] You may include the appearance of the client, interpretation of client's behavior etc. Use words such as appear, seem etc. Assess challenges or barriers in obtaining housing or completing goals. [Space] State what the next plan of action will be. You may mention specific dates or times in which goals or follow-up is expected. Plan should reflect Family Plan. Client Updates: (<- insert key word) Example key words: employment, referral follow-up, client requests, etc. Include client's progress on goals indicated on Family Plan. You may include clients housing expectations. Include facts only. This may include but are not limited to documents obtained from client and reason for communication (ie. Follow up, re -certification and intake), method of contact le. phone, face-to- face or email. You may include statements or quotes from client ie. Client stated he is having difficult time finding employment. [Space] You may include the appearance of the client, interpretation of client's behavior etc. Use words such as appear, seem etc. Assess challenges or barriers in obtaining housing or completing goals. [Space] State what the next plan of action will be. You may mention specific dates or times in which goals or follow-up is expected. Plan should reflect CTl Plan. Use of CFC Childcare/Women's Philanthropy/ Nancy Chase funds These unique funding sources allow case managers to financially assist our clients with certain requests outside of rental assistance. Women's Philanthropy allows FF to assist women with a variety of unique needs such as car repair, furniture etc that will further their progress towards stability. The Nancy Chase fund is specifically used to address and assist the needs of the children within the program. CFC childcare assistance allows FF to pay for childcare costs as a bridge for families served under that grant in RRH or interim transitional housing. Consult with Housing Program Manager before use of the above mentioned funds. FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE In the case note, CM will include the name of the client, date the check was issued, dollar amount of the check, the reason for the use of funds and if applicable, what was purchased. FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE Referrals FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE • Referral Date- will be the date that you initially made the referral • Referral Service- CM will select an item from the service drop down list (see image 2) • Refer to Provider- CM can click on the magnifying glass icon to see if provider is already listed o If provider is not listed CM will enter provider name in the space provided o A search pop up box may appear, CM can just cancel out of this step and save referral • Status- Select "Referral Made" • Comments- CM can add comments as necessary . .. # a Reporting .. � . Fonder .Amallnt Funded .Start Date : End Date Famples ': Due to . Quarter 1 Quarter 2 CRuarter 3 Quarter 4 Housing Status lib€eta System Performance Unique Documents Needed Servke/Use Note ' Social Notes . _._ Serve Farider — Serve h4easures •, LAw—ge Data Q.1ity" 95% Ht1D Is, K,7tien, Lead Category I- Homeless or highs, Screening, Meeds Assessment, " Annual Annual APR 1013//16 9j {Ptme not meant for human 2- t:ntryfrom Homelewness• Rent Reasonableness, HUD•{tRH $7DCI,0(Y0 7/1,12616 6J-3[111[H8 yin Duo 9/301 habitation and Emergent., 100% Homeless . 9/30/18) E, 9/3011G 12/31/tfi 3/31f17 1/17 6/W/1- 6/30/17 Shriner on10'M00 r M. 3. Return to ffumefessness- Certificown/V,wfiaHon Voucher applies under 15% Signed by CM, 3rd party d. PHFaits-90%or higher I- Average Data (Warrty-05% I.—n.,%verNlcatian HUn 1n rp tfan, LaaA _ Category 1, Homeless or hog I— 5c reening, Maeda Assessment, 17/lI4 fi 711/t7- 511/17- Rli/17- (PWM not meant tar human 2. Lntry from He melcasrtess Rem Reasonatikness, Pathways of Hope $59,251 11/11201fi 10/31f2018 14 Wr,tltiy habitation and EmergancY I00Y Homeless I/9VI7 4/30117 7/31117 10131117 Shelter only) -motel wAth 3. Rahanm to Npnk-6Cssness- Cart,fication)Veriticaatjnn Voucher DOES NOT apply order 15% Signed by CM, 3rd party 4. PH Uits- 80%.,higher homeless veaf cation 5erv4crs for All Family Members, RM - 1. Average Data Quality- 95% meta sess[ans (daily) Servims for higher Children D-S- ho t1h insurance (2 . Category 1- FtomO— 2.FMy (acsa . rrm Hulr ele5511e55- 5er ia:ea} on. time Only When the N dinp cycle CK - $18,200 711/2016 6/30/2018 20 Q— tery 7/1116- 10/1/16- 1/1117- 4/1117- Category 2-At tR9l Entry ad Exit aCFCOC entry/exit survey Servlces ends on 6f 30all chddre D- • 913011ti 17J31.1te 3/?1/17 6/30f 17 Risk of Losing Housing 3. Return to Ilomeleasness- 5uppLimrnlal Survey fw HOH (Mamt*t)- Case 5 mo,r have an exit Crmc - tinder 15% M.nagement Meeting s,xrvary dated 6130 - 4. Pit Exits-90%or higher Develnprnental =eeninli ReaJm, materials Irdormalion and ---- -- 1. Averape Data Quality 95% Referrals --- higher 9I1%16- 1211/16- 311/17- 6/1/17- Category 1- Hrnnelc•s•: 2. Cntry from Hornelesaaes United Way Main $1un,ap gjvf n16 g/9If2418 20 Quaxtaxy 11/3G/i6 2/28f17 5/31/17 8/M/17 Category 2-At Imminent 100% Risk of Losing Houshig 3- Rewrn M Homelessness- ' undue 15% 6/30/2018 200 4. PH Exft -80%or hgtf eg Irvine CGBG $21,951 711/2016 Q,kartery 711/16- 10/1/Sir 1/1/17- 4/1/17- _ IIOA's fear S�ev:rnn.nh homes 9/3D/15 7/1/16 12/31/16 3/31/17 6130/17 Newpot8each $iS,ODD 7f1/2016 G/30f2018 lfa5 Quarters 10/111& 1/1/17- 411/17- £DBG....,... 9/30/16 12/311/6 3131117 6/9o/17 Su ppartTllprug— Dvuct rcfunal from City of Costa Mesa CDDG $14, 5W 71112016 6f30/-Lu18 III 4uartery 7/1f16 10/I/16- VVI-1- 411/17- Costa Mesa mpmsentative 9/3n/16 12131/16 3/91/17 0011'r us, a 3 ycae jva.riiiad tuej to . 7/1/2016 6/3012DIS 1f1/17- the nny of Costa Mesa Hutnan�opticns $25.000 15 7r'1115 1011/lti- 4f1/L7- _t Hf15 .:.'•, 9/W/16 17131/16 3/31/17 6/30/17 ._ ._...__ Pay for child®re, car �- rurrlirme, ' Wom.en's i•. $5,400 9/1/1016 6/31/2016 9/1/1& 121111rr 311/17- 6/1/17- HQn5ing fa mules with mr-digl servim&, anoal Philatltlir0 Fund PY I1/30 16 / 2 2811P 1 5 3 17 I U' 3 17 $f 11 women in 1 he family vouchers and more. Not to exceed $2,000 per FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE File Management Creating New Family File • Before creating the file make sure all HMIS enrollment forms and program documents provided are completely filled out and up to date c Note all areas where information is missing to request from client during the next in person meeting • Case manager will use the P-Touch to create the following labels o Client name • Last Name, First Name ■ If there are two adults in the family only add the Head of Household to label o Tab I- Personal o Tab II- Financial o Tab III- Rapid Rehousing o Tab IV- Interim o Tab V- Case Management o Tab VI- Program • Use HP File Index as a guide for proper placement of documents within file Maintaining Record Keeping • It is required for the following documents to be filled/collected regularly; o Budgets o Paystubs O Home inspection forms o Gift card verifications o Rent receipts ■ Copies of receipts for Rapid Re -housing clients will be filed under Tab V- Housing ■ Rent receipts for Interim Housing will be kept by the Operations Associate ■ FIRS will provide CM with a monthly ledger or what has or has not been paid by the client o Food pantry lists o Correspondence with client ■ Pertinent information that would affect their housing program • Change in child support income letter, court letters, cash aide award letters, etc. • Data Entry Clerk will perform audit on any new files on a weekly basis o Any corrections will be flagged with an attached explanation as needed HOUSING PROGRAM FILE INDEX CLIENT TRACK ID: HMIS ID: TH/IH RRH Grant Tab I —Personal Tab 11 - Financial ❑ ❑ HP File Index ❑ ❑ Income calculation worksheet ❑ ❑ Homeless Certification ❑ ❑ Entry Income Verification ❑ ❑ 3rd party verification of homelessness ❑ ❑ Income Guidelines. ❑ ❑ FF Motel Reservation forms (If applicable) ❑ ❑ HMIS Enrollment Forms Divider ❑ ❑ CFC Client Forms (only if client is CFC funded) ❑ ❑ Current Income Verification ❑ ❑ HMIS Consent Form ❑ ❑ Monthly Budgets ❑ ❑ Self -Declaration of Income Divider ❑ ❑ Self -Declaration of Financial Resources ❑ ❑ HMIS Report (If applicable) ❑ ❑ Bank Statements-3 months ❑ ❑ Request for Services Form ❑ ❑ CES Referral ❑ ❑ Picture ID ❑ ❑ Social Security Card ❑ ❑ Immunization Card (0-5 years) ❑ ❑ School Enrollment Verification (5+years) ❑ ❑ Birth Certificates -all house hold members ❑ ❑ Medical insurance Cards ❑ ❑ Court/Custody Documentation (If applicable) ❑ ❑ Disability Documentation (If applicable) ❑ ❑ Exit Documents - HMIS forms, CFC survey (If applicable) Tab III — Rapid Rehousing Tab IV — Interim ❑ ❑ Schedule of Rent Payments ❑ ❑ Current Lease Agreement ❑ ❑ Lease ❑ ❑ Residential Rent ❑ ❑ Check Requests ❑ ❑ Exhibit A ❑ ❑ Rent Receipts ❑ ❑ Rental Formula ❑ ❑ Key Exchange Agreement ❑ ❑ Drug Test ❑ ❑ Rapid Re -Housing Needs Assessment ❑ ❑ Misconduct Act ❑ ❑ ESG Lead Screening Worksheet ❑ ❑ Housing Inspection Forms (If applicable) ❑ ❑ Rent Reasonableness Checklist and Certification ❑ ❑ 30-Day Notice/Extension ❑ ❑ Minimum Standards for Permanent Housing ❑ ❑ Security Deposit Return ❑ ❑ Housing Inspection Forms (If applicable) Tab V — Case Management Tab VI - Program ❑ ❑ CTI Plan Both Programs ❑ ❑ Client Email Correspondence ❑ ❑ Program Offer Letter ❑ ❑ Crisis Documentation (If applicable) ❑ o Termination of Assistance Policy ❑ ❑ Signed gift card copies (If applicable) ❑ ❑ Termination of Housing Process of Appeals ❑ ❑ Filled food pantry forms (If applicable) ❑ ❑ Communication Disclosure ❑ ❑ Program Contract ❑ ❑ Grievance Policy ❑ ❑ Consent to Exchange Information ❑ ❑ Consent for Services ❑ ❑ Tenant Screening Form (If applicable) ❑ ❑ Credit Report ❑ ❑ Background Check Disclosure ❑ ❑ Printed background check ❑ ❑ Employment Agreement (if applicable) CASE MANAGER NAME: FAMILIES FORWARD DIGNITY - EMPOWERMENT • HOPE Family Meetings Preparation for Initial family meeting ■ Meet with Housing Program Manager to review all current family barriers o This information with will be used to develop a CTI plan ® The following information will be included in clients CTI plan O Name of adults in household O Date the CTI plan was created O Phase 1 ■ Assessment of the family and their support network, decide on areas of focus, begin connecting to appropriate resources O Phase 2 ■ Evaluate progress with areas of focus and connections to those areas O Phase 3 ■ Finalize all connections made to areas of focus, ■ Family will have identified continuous support, program end O Areas of Focus ■ CM and client will collaborate on the areas of focus ■ Areas of focus are goals with action steps listed for each phase ■ 6 areas of focus include: counseling and psychiatric treatment, career coaching, substance abuse treatment, housing crisis prevention & management, and family intervention O Recertification/Extension ■ If a client requests or CM feels the need to extend the time in the program, the CM will present recommendations and progress for the family to the housing committee during the case management meeting at least a month prior to exit Initial family meeting ® During the initial family meeting the following items will be reviewed with the family o Client Handbook ■ Review the Client Handbook with the family a The purpose of the client handbook is to allow for the family to have an organized tangible place to keep all documents that they receive and to have a place to keep track of all appointments. o CTI Plan ■ Make note of any goals family would like to add to their CTI plan FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE ■ Explain to the family the program expectations and importance of regular communication with CM • Cell phone (call or text) • Office direct line • Email o Review Schedule of Rent Payment (SORP) with family ■ During this time CM will inform the family of projected program end date and what the family is financially responsible for towards monthly rent and/or utility payments o If there are missing documents be sure to have those documents present for completion during this initial meeting ■ This includes missing supporting documents and missing information or signatures o Food Pantry Form ■ Review with family the food pantry policy ■ Make family aware that they can access food once a week ■ All forms must be filled out and submitted by gam Monday morning for pick up Tuesday through Thursday ■ Inform family to communicate with CM on any special requests that are not regularly available in the food pantry • Diapers in larger sizes • Food allergies • In some cases gift cards may be made available to Purchase such items o If gift card is provided to client CM will make a copy of gift card and have client sign and date the copy ■ Copy is then filed in CM section of client file Family meeting • CM is required to meet with family in person at least once a month o Depending on family need, program length and barriers CM may need to meet with family weekly o CM will maintain communication with family outside of the scheduled monthly family meeting as needed • During monthly meeting CM will review family progress with initially established areas of focus • CM is responsible for addressing any new barriers presented at family meeting or via various methods of communication • Family will provide CM with; o Monthly budget o Current paystubs FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE o Rent if appropriate (Interim Transitional Housing Families) ■ Money in cash cannot be accepted offsite O Utility payments (Interim Transitional Housing Families) • Utility payments are due two weeks after CM provides family with copy of utility bills • Utility payments are rounded to the nearest dollar amount and family is notified of the total amount due o Any other verification documents that CM has requested FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE Case Management Best Practices ❑ Meet at least once a month in person o Review CTI plan o Discuss family progress towards areas of focus o Discuss barriers (new or existing) ■ Refer family to appropriate resources o For "pending" clients, discuss progress on housing search and employment status if unemployed ❑ Collect previous months budget o During monthly meeting review client's budget in detail o Refer family to Financial Literacy if needed ❑ Collect rent receipt o For RRH By the 3rd of the month o For TH/INT on or before the 15t of the month ❑ Send out utility bills (TH/INT) o Collect utility bill payment 0 2 weeks from when CM sent out payment o Amount due for utilities; $ ❑ Collect previous months paystubs ❑ Send out check requests for FF rent portion (RRH) o No later than the 3rd Monday of each month FAMILIES FORWARD DIGNITY - EMPOWERMENT • HOPE Case Management Deadlines Check Requests • Rent Check Request (Rapid Re -Housing) o Rent check requests are due on or before the third Monday of the month • Check Request Deadline o Check requests must be submitted by 11AM every Wednesday • When client makes a request that will result in cutting a check CM must get the expense approved by management team e At this time you may make client aware if the expense was approved or denied • Check requests are completed for the following items o Rent for Rapid Re -Housing families o Childcare assistance o Car repair assistance o Security deposit reimbursement o Any other expenses that have been approved • When completing check requests make sure all fields are included which include: o Urgent request (if applicable) o Date check request is completed o Amount o Check payable to: o Address (of vendor) O CM name (requested by) o Indicate new or repeat vendor ■ If new_verld9_r_a_/aL-2must he attached to re_qu.esLands.ave.d to the "G" Drive o CM will always mark "return to requester" CM must always have a copy of the check and check request to file o Purpose o Month o Grant o Client name o Current client address o At this point CM will make a copy of the check request o First approval signature o Second approval signature (if amount is $1,000 or over) ■ See sample check request attached Once check request is complete submit to accounting When check has been given to CM make a copy of the check o Place check request copy with copy of check in client file Interim Housing Deadlines • CM -Case Manager; HRS-Housing Resource Specialist; FM -Facilities Manager; FA -Facilities Assistant; OA-Operations Associate FAMILIES FORWARD DIGNITY - EMPOWERMENT • HOPE WHEN WHAT - WHO Move In Family is given all keys (mailbox, home, garage) and CM, OA introduced to new home. 3 — S business Once the family has moved in (physically occupying the unit) OA days after the Home Orientation is conducted within 3-5 business move in days, At this time Tenant Education, Move -in Inspection, and Affordable Housing List is given. First Tuesday Monthly Home Visits are conducted the first Tuesday of FM, OA of every every month for the entire program period month 1 week after If family does not pass Home Visit the recheck is conducted OA, CM if home visit the following Tuesday. Allowing one week for the family to available rectify the problem. During If there is an emergency maintenance problem (affects FM Tenancy habitability —relating to sanitation, water, heat, etc.) family is instructed to call Facilities Manager During If there is a non -emergency maintenance problem family is FM Tenancy_instructed to e-mail Facilities Manager. During Facilities Manager will attempt to fix in-house and will FM Tenancy schedule outside service if needed. During All maintenance follow up with tenant is conducted by FM Tenancy Facilities Manager in a timely manner. During When HOA complaints are received pertaining to client, the CM, HRS Tenancy issue is corrected and follow up is written to HOA. The Template can be found on the G drive — G:\Farms\Program Farms\Transitional Housing Farms\Property Management. During When HOA complaints are received pertaining to HRS Tenancy maintenance/non-client, the issue is corrected and follow up is written to HOA 30 days Notice to vacate is given to family and PM team before move out FAMILIES FORWARD DIGNITY - EMPOWERMENT • HOPE 7-14 days Final home visit is conducted. Move out inspection is CM, OA, FM before move scheduled with client out 7-14 days The Move -Out inspection is completed with tenant to CM, OA, FM before move discuss potential Security Deposit deductions and move out out checklist. The tenant is to provide CM with furniture request at this time. Any permissible furniture to be taken with tenant will be written on their move out inspection form. ASAP Any exceptions of lease extensions given to client must be i CM shared with PM team as soon as possible. {I Day of Move Key exchanged is performed at the home face to face on the CM, OA Out family's last day. Walk through should be done by CM at this time. If unit is not acceptable CM is to work with client to resolve issues. If family is not ready, key should not be exchanged. Within 3 days First inspection is completed to evaluate any damages or FM post move excessive wear and tear to be deducted from Sec. Deposit out _Within 21 _____ Security.Deposit is returned to family.wi.thin21-days-_f.,,., days post move out. Only damage to the unit, cleaning fees and/or move out utility fees may be deducted from the security deposit. 1-2 weeks Home is evaluated for fix -its, furniture replacement and first FM, FA post move clean sweep. Maintenance is scheduled and conducted. out Facilities Manager conducts final Maintenance Walkthrough with Maintenance Checklist for property file -- Also leave two light bulbs and one 9V battery per unit. 1-2 weeks Professional cleaners are scheduled for full cleaning FM post move out 1-2 weeks Painters are scheduled if necessary FM post move out FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE 1-2 weeks Carpet cleaner scheduled FM post move out ASAP Family Profile is given to PM team as soon as available even CM if not finalized Once FP is Warehouse and home are evaluated to match Family FM, FA received (2-3 Profile. Items are pulled and unit is adjusted to family weeks post profile. One corkboard per child's room is supplied. move out) ASAP If Family Profile changes adjustments to unit are made CM, CIA, FM, FA accordingly. ASAP Counselors are notified that the unit is ready to go. HRS, OA 3 days before !Notification to PM team of new family moving in at least 3 CM move in days prior to their move in >1 week post If unit sits for a period of time (over two weeks) spiffing is CIA Group Visit _ necessary for dust build-up just prior to family moving in ASAP Throughout entire process make sure the Whiteboard is CIA updated so that all units have the most current information Family Moves in and the process re -starts! Data Deadlines A New family data o All families need to be entered into HMIS and Client Track (CT) within three days of receiving case assignment which is the "Match" date from the Coordinated Entry Systems (CES) A Services o All services need to be entered into CT and HMIS within three days of rendered service date a Exiting Families Upon Completion of Program c All families need to be exited from HMIS and CT within 3 days from move -out date Y Case Notes o Case notes need to be entered no more than three days after family meeting FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE Case notes are required for the following: • Entry of the family into housing case note • First family meeting case note • Family meeting case note for each month in the program • Gift card services provided • Emergency with client, family or home (entered immediately) • Information or interaction CM feels important to document • Exit case note Families Forward Exhibit C Gross Income Calculation Form Income Calculation Worksheet • Semi -Monthly pay cycles are usually 15 days or longer from the 1st - 15th and the 16th - 30th/31 st • Semi -Monthly salaried wage stubs wi!I often show 86.66 or 86.67 under the "hours" section • Bi-Weekly pay cycles are usually 14 days and begin on the same day of the week and end on the same day of the week from pay cycle to pay cycle For migrant workers, monthly gross Income is coputed by averaging the total gross income received during the previous 12 months and is NOT recalculated until the next annual certification Select Appropriate Income Pay Cycle for Applicant Household Weekly: (52 pay periods annually) Member Name: Weekly Average $ X 52 pay periods $ gross annual income Member Name: $ + $ + $ _ $ / 3 = $ Weekly Average $ X 52 pay periods $ gross annual income Si -Weekly: (26 pay periods annually) Member Name: S + S + $ = 5 Bi-Weekly Average $ X 26 pay periods $ Member Name: Bi-Weekly Average $ X 26 pay periods $ Semi -Monthly: (24 pay peroids annually) Member Name: / 3 = $ gross annual income / 3 = $ gross annual income $ + $ + $ _ $ / 3 = $ Semi -Monthly Avg. $ X 24 pay periods $ gross annual income Member Name: $ + $ + $ _ $ / 3 = $ Semi -Monthly Avg. $ X 24 pay periods $ gross annual income Monthly: (12 pay periods annually) Member Name: $ X 12 pay periods $ gross annual income Member Name: $ X 12 pay periods $ gross annual income Fluctuating: use for seasonal, migrant, agricultural, commissions Member Name: $ gross annual income Member Name: $ gross annual income Total Household Annual Income From All Sources Listed Above: FAMILIES FORWARD DIGNITY • EMPOWERMENT - HOPE Families Forward Housing Program Self -Declaration of Income This is to certify the income status for the applicant. Income includes but is not limited to: •The full amount of gross income earned before taxes and deductions. •The net income earned from the operation of a business, i.e., total revenue minus business operating expenses. This also includes any withdrawals of cash from the business or profession for your personal use. •Monthly interest and dividend income credited to an applicant's bank account and available for use. •The monthly payment amount received from Social Security, annuities, retirement funds, pensions, disability and other similar types of periodic payments. •Any monthly payments in lieu of earnings, such as unemployment, disability compensation, SSI, SSDI, and worker's compensation. •Monthly income from government agencies excluding amounts designated for shelter, and utilities, WIC, food stamps, and childcare. •Alimony, child support & foster care payments received from organizations or from persons not residing in the dwelling. •All basic pay, special day & allowances of a member of the Armed Forces excluding special pay for exposure to hostile fire. I certify that the information below and any other information I have provided in applying for Families Forward Housing Program assistance is true, accurate and complete. Check only one and complete only that section: o I certify that I currently receive the following income: 0 ource: Amount: Frequency: o Source: Amount: Frequency: o I certify that I do not have any income from any source at this time. Applicant Name (signed): o I certify that I currently receive the following income: o Source: Amount: o Source: Amount: Date: Freq uency: Frequency: o I certify that I do not have any income from any source at this time. Applicant Name (signed): Date: Case Manager (printed): Date: Case Manager (signed): Date: Families Forward FAMILIES FORWARD DIGNITY • EMPOWERMENT - HOPE Families Forward Housing Program Self -Declaration of Financial Resources This is to certify the financial status for the applicant. Do you presently have a checking account? ❑Yes ❑ No If No, why not? Do you have a savings account? ❑Yes El No If Not, why not? Do you presently have one or more active credit cards? ❑Yes []No If Yes, how many? If No, have you ever had a credit card? ❑Yes ❑No Please list ALL of your debts and expenditures (if you need more space, please attach separate sheet) Uwed to: 1 otal Amount: Monthly I,a ments: Balance Uue: 1. 2, 3 4. 5. Have your wages been garnished in the last year, or are you at risk of having your wages garnished? ❑Yes []No Are you in Bankruptcy now or are in the process of filing for bankruptcy? ❑Yes ❑No Do you owe money to friends or family? ❑Yes ❑No If Yes, amount you owe: $ Do you owe money to a previous landlord? ❑Yes ❑ No If Yes, amount owed: $ Do you have past due household bills? ❑Yes ❑No If Yes, amount of balance $ Are you carrying a balance on credit cards(s)? ❑Yes ❑No If Yes, amount of balance(s): $ Do you have outstanding student loans? ❑Yes ❑No If Yes, amount of outstanding loan(s): $ Do you have any outstanding medical bills? Families Forward FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE El Yes El No If Yes, amount of outstanding balance: $ Have your utilities been disconnected in the past year or as you at risk of having your utilities disconnected? ❑Yes ❑No Has your car been repossessed in the past year or is at risk of being repossessed? ❑ Yes ❑ No Are collection agencies presently contacting your about unsettled claims? ❑Yes ❑No Do you owe support (This includes current child support and child support that is in arrears)? ❑Yes ❑No If Yes, please list amount: Current monthly: In arrears: Are you owed child and/or spousal support? ❑Yes ❑No If Yes, please discuss: 1 certify that the information above and any other information 1 have provided in applying for Families Forward Housing Program assistance is true, accurate and complete, Applicant Name (printed): Applicant Name (signed Applicant Name (printed): Applicant Name (signed): Case Manager (printed): Case Manager (signed): Date: Date: Date: Date: Date: Date: Families Forward FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE Enrollment Process: ® Once CM receives match, CM will call client within 24-48 hours to schedule appointment for Packet Review and Tenant Screening with CM and HRS ■ Appointment takes approximately 2 hours to complete ■ CM to send calendar and google doc invite to HRS for date and time of appointment o Client to bring the required family documents: ■ Proof of Income (one month's worth; last 3 paystubs) ■ Birth certificates ■ ID's for adults ■ Social security cards ■ Immunization records for children 0-5 or school enrollment verification for children 5+ ■ Medical cards ■ Current pay stubs or any other income source ■ Bank statements ■ Car registration and insurance ■ Custody/court documentation (If applicable) ■ Disability forms (If applicable) • Include Dara Entry Clerk to calendar invite (availability to attend appointment based on DEC capacity) o DEC will make copies of all family documents during appointment • Begin Enrollment Process (Packet Review and Tenant Screening): o CM to start meeting with review of homeless certification from CES ■ CM to gather current documentation from client ■ CM to provide Homeless Certification form for client to sign and date, as well as provide the homeless documentation from agency, emergency shelter, church and/or social service agency ■ If client is stating the family is sleeping in their vehicle, CM will complete a vehicle inspection in the FF parking lot. CM will sign Homelessness Certification verifying homelessness FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE o Once the documentation is collected, CM will proceed with the Packet Review o For any family that does not re -certify and/or cannot provide the above information, will be sent back to CES • CM to update HIC with this information • HIC will send update to CES on a weekly basis c CM will gather all family documents and hand over to DEC o HRS will conduct Tenant Screening in which housing history and credit report will be reviewed c For packet review, CM will fill out an enrollment packet for each member of the household ■ CM to use this time to ask about family and homeless history ® CM will also review and verify income documentation provided by client. N Adults earning any form of income must sign the Self Declaration of Income and provide any of the following forms of verification that are applicable: ■ Last 3 paystubs for earned income • If paystubs are not available, then an offer letter as it relates to a new job, that has not yet started, can be submitted • An award letter on letterhead for Cashaid, Disability and/or SSI ■ Court paperwork as it relates to child support or alimony ■ If the above mentioned documents are unavailable and CM has done their due diligence in trying to obtain documents (as noted in emails and/or case notes) CM will use the Self Declaration of Income as proof of income for the family o CM will plug in this information into the Income Calculation Worksheet to determine if family meets income guideline requirements o Based on the information, circle the income bracket the family falls under on the annual HUD guidelines document CDBG participants must fall under extremely low to low-income bracket o Once packets are completed, CM will explain and obtain clients) signature on all program documents during appointment FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE O Complete Enrollment Process o CM will submit the completed HMIS packets and family documents to DEC to enter information in both HMIS and Client Track Systems o CM will receive client information from Data Entry Clerk (DEC) after client information is entered into both Client Track and HMIS systems DEC will provide information to CM within 24 hours CM will pull an HMIS report and Background Check on all adults in the household ® Note: o What program is the family entering (Interim Transitional Housing- I- TH or Rapid Re -housing)? All I-TH clients are required to complete a drug screen prior to program entry as part of a needs assessment and not as a determinant of program entry ® CM provides a referral to all of the adults in the household to complete a drug screening at a predesignated location ® Clients must complete the Packet Review and Tenant Screening in order to complete enrollment into the housing program i Active vs Pending Clients o Once the enrollment process is completed, CM will maintain a caseload consisting of both Active and Pending clients Active clients- homeless families that are currently in Interim Transitional Housing or Rapid Re -Housing Programs Pending clients- homeless families that have been matched to Families Forward and have completed the enrollment process, but have yet to identify permanent housing o CM and HRS must check in weekly with family until housing is identified i Family will be sent back to CES for non-compliance with program rules or ceases communication with CM Families Forward Exhibit D Household Budget Worksheet FAMILIES FORWARD Name: Month/Year: FAMILIES FORWARD DIGNITY • EMPOWERMENT • MOPE Family Meetings Preparation for Initial family meeting o Meet with Housing Program Manager to review all current family barriers o This information with will be used to develop a CTI plan ® The following information will be included in clients CTI plan o Name of adults in household o Date the CTI plan was created o Phase 1 ■ Assessment of the family and their support network, decide on areas of focus, begin connecting to appropriate resources o Phase 2 ■ Evaluate progress with areas of focus and connections to those areas O Phase 3 ■ Finalize all connections made to areas of focus, ■ Family will have identified continuous support, program end o Areas of Focus ■ CM and client will collaborate on the areas of focus ■ Areas of focus are goals with action steps listed for each phase ■ 6 areas of focus include: counseling and psychiatric treatment, career coaching, substance abuse treatment, housing crisis prevention & management, and family intervention o Recertification/Extension ■ If a client requests or CM feels the need to extend the time in the program, the CM will present recommendations and progress for the family to the housing committee during the case management meeting at least a month prior to exit Initial family meeting ® During the initial family meeting the following items will be reviewed with the family O Client Handbook ■ Review the Client Handbook with the family ■ The purpose of the client handbook is to allow for the family to have an organized tangible place to keep all documents that they receive and to have a place to keep track of all appointments, o CTI Plan ■ Make note of any goals family would like to add to their CTI plan FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE: Explain to the family the program expectations and importance of regular communication with CM • Cell phone (call or text) • Office direct line • Email O Review Schedule of Rent Payment (SORP) with family During this time CM will inform the family of projected program end date and what the family is financially responsible for towards monthly rent and/or utility payments O If there are missing documents be sure to have those documents present for completion during this initial meeting a This includes missing supporting documents and missing information or signatures O Food Pantry Form • Review with family the food pantry policy • Make family aware that they can access food once a week • All forms must be filled out and submitted by gam Monday morning for pick up Tuesday through Thursday ■ Inform family to communicate with CM on any special requests that are not regularly available in the food pantry • Diapers in larger sizes • Food allergies • In some cases gift cards may be made available to purchase such items o If gift card is provided to client CM will make a copy of gift card and have client sign and date the COPY ■ Copy is then filed in CM section of client file Family meeting • CM is required to meet with family in person at least once a month o Depending on family need, program length and barriers CM may need to meet with family weekly o CM will maintain communication with family outside of the scheduled monthly family meeting as needed • During monthly meeting CM will review family progress with initially established areas of focus • CM is responsible for addressing any new barriers presented at family meeting or via various methods of communication • Family will provide CM with; O Monthly budget O Current paystubs FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE o Rent if appropriate (Interim Transitional Housing Families) ® Money in cash cannot be accepted offsite o Utility payments (Interim Transitional Housing Families) ■ Utility payments are due two weeks after CM provides family with copy of utility bills ■ Utility payments are rounded to the nearest dollar amount and family is notified of the total amount due o Any other verification documents that CM has requested FAMILIES FORWARD DIGNITY • EMPOWERMENT • HOPE Case Management Best Practices ❑ Meet at least once a month in person o Review CTI plan o Discuss family progress towards areas of focus O Discuss barriers (new or existing) Refer family to appropriate resources O For "pending" clients, discuss progress on housing search and employment status if unemployed ❑ Collect previous months budget o During monthly meeting review client's budget in detail o Refer family to Financial Literacy if needed ❑ Collect rent receipt O For RRH By the 3rd of the month O For TH/INT on or before the 1st of the month ❑ Send out utility bills (TH/INT) O Collect utility bill payment 0 2 weeks from when CM sent Out payment o Amount due for utilities: $ ❑ Collect previous months paystubs ❑ Send out check requests for FF rent portion (RRH) o No later than the 3rd Monday of each month Families Forward Exhibit E Lead -Based Hazard Information Pamphlet "Protect Your Family from Lead in your Home" ESG Lead Screening Worksheet About this Tool The ESG Lead Screening Worksheet is intended to guide grantees through the lead -based paint inspection process to ensure compliance with the rule. ESG staff can use this worksheet to document any exemptions that may apply, whether any potential hazards have been identified, and if safe work practices and clearance are required and used. A copy of the completed worksheet along with any additional documentation should be kept in each program participant's case file. Please seethe ESG Lead -Based Point Requirements Summary for additional information, INSTRUCTIONS To prevent lead -poisoning in young children, ESG grantees must comply with the Lead -Based Paint Poisoning Prevention Act of 1973 and its applicable regulations found at 24 CFR 35, Parts A, B, M, and R. Under certain circumstances, a visual assessment of the unit is not required. This screening worksheet will help program staff determine whether a unit is subject to a visual assessment, and if so, how to proceed. A copy of the completed Worksheet along with any related documentation should be kept in each program participant's file. Note: ALL pre-1978 properties are subject to the disclosure requirements outlined in 24 CFR 35, Part A, regardless of whether they are exempt from the visual assessment requirements. BASIC INFORMATION Name of Participant: Address: Unit Number: City: State: Zip: Case Manager: PART 1: DETERMINE WHETHER THE UNIT IS SUBJECT TO A VISUAL ASSESSMENT If the answer to one or both of the following questions is'no/ a visual assessment is not triggered for this unit and no further action is required at this time. Place this screening Worksheet and related documentation in the program participant's file. If the answer to both of these questions is `yes,' then a visual assessment is triggered for this unit and program staff should continue to Part 2. 1. Was the leased property constructed before 1978? ❑ Yes ❑ No 2. Will a child under the age of six be living in the unit occupied by the household receiving ESG assistance? ❑ Yes ❑ No ESG Lead Screening Worksheet 1 Exhibit E PART 2: DOCUMENT ADDITIONAL EXEMPTIONS If the answer to any of the following questions is 'yes,' the property is exempt from the visual assessment requirement and no further action is needed at this point. Place this screening sheet and supporting documentation for each exemption in the program participant's file. If the answer to all of these questions is 'no,' then continue to Part 3 to determine whether deteriorated paint is present. 1. Is it a zero -bedroom or SRO -sized unit? ❑ Yes ❑ No 2. Has X-ray or laboratory testing of all painted surfaces by certified personnel been conducted in accordance with HUD regulations and the unit is officially certified to not contain lead -based paint? ❑ Yes ❑ No 3. Has this property had all lead -based paint identified and removed in accordance with HUD regulations? ❑ Yes ❑ No 4. Is the client receiving Federal assistance from another program, where the unit has already undergone (and passed) a visual assessment within the past 12 months (e.g., if the client has a Section 8 voucher and is receiving ESG assistance for a security deposit or arrears)? ❑ Yes (Obtain documentation for the case file.) ❑ No 5. Does the property meet any of the other exemptions described in 24 CFR Part 35.115(a). ❑ Yes ❑ No Please describe the exemption and provide appropriate documentation of the exemption. PART 3: DETERMINE THE PRESENCE OF DETERIORATED PAINT To determine whether there are any identified problems with paint surfaces, program staff should conduct a visual assessment prior to providing ESG financial assistance to the unit as outlined in the following training on HUD's website at: http://www.hud.gov/offices/lead/trai ni ng/visualassessment/h00101.htm. If no problems with paint surfaces are identified during the visual assessment, then no further action is required at this time. Place this screening sheet and certification form (Attachment A) in the program participant's file. If any problems with paint surfaces are identified during the visual assessment, then continue to Part 4 to determine whether safe work practices and clearance are required. Exhibit E 1. Has a visual assessment of the unit been conducted? ❑ Yes ❑ No 2. Were any problems with paint surfaces identified in the unit during the visual assessment? ❑ Yes ❑ No (Complete Attachment A— Lead -Based Paint Visual Assessment Certification Form) PART 4: DOCUMENT THE LEVEL OF IDENTIFIED PROBLEMS All deteriorated paint identified during the visual assessment must be repaired prior to clearing the unit for assistance. However, if the area of paint to be stabilized exceeds the de minimus levels (defined below), the use of lead safe work practices and clearance is required. If deteriorating paint exists but the area of paint to be stabilized does not exceed these levels, then the paint must be repaired prior to clearing the unit for assistance, but safe work practices and clearance are not required. 1. Does the area of paint to be stabilized exceed any of the de minimus levels below? • 20 square feet on exterior surfaces ❑ Yes ❑ No • 2 square feet in any one interior room or space ❑ Yes ❑ No e 10 percent of the total surface area on an interior or exterior component with a small surface area, like window sills, baseboards, and trim ❑ Yes ❑ No If any of the above are `yes,' then safe work practices and clearance are required prior to clearing the unit for assistance. PART 5: CONFIRM ALL IDENTIFIED DETERIORATED PAINT HAS BEEN STABILIZED Program staff should work with property owners/managers to ensure that all deteriorated paint identified during the visual assessment has been stabilized. If the area of paint to be stabilized does not exceed the de minimus level, safe work practices and a clearance exam are not required (though safe work practices are always recommended). In these cases, the ESG program staff should confirm that the identified deteriorated paint has been repaired by conducting a follow-up assessment. If the area of paint to be stabilized exceeds the de minimus level, program staff should ensure that the clearance inspection is conducted by an independent certified lead professional. A certified lead professional may go by various titles, including a certified paint inspector, risk assessor, or sampling/clearance technician. Note, the clearance inspection cannot be conducted by the same firm that is repairing the deteriorated paint. 1. Hasa follow-up visual assessment of the unit been conducted? ❑ Yes ❑ No 2. Have all identified problems with the paint surfaces been repaired? ❑ Yes ❑ No u Exhibit E 3. Were all identified problems with paint surfaces repaired using safe work practices? ❑ Yes ❑ No ❑ Not Applicable —The area of paint to be stabilized did not exceed the de minimus levels. 4. Was a clearance exam conducted by an independent, certified lead professional? ❑ Yes ❑ No ❑ Not Applicable —The area of paint to be stabilized did not exceed the de minimus levels. 5. Did the unit pass the clearance exam? ❑ Yes ❑ No ❑ Not Applicable —The area of paint to be stabilized did not exceed the de minimus levels. Note: A copy of the clearance report should be placed in the program participant's file. 4ESG •Screening Worksheet I Exhibit E ATTACHMENT 1: LEAD -BASED PAINT VISUAL ASSESSMENT CERTIFICATION TEMPLATE certify the following: • I have completed HUD's online visual assessment training and am a HUD -certified visual assessor. • 1 conducted a visual assessment at on O No problems with paint surfaces were identified in the unit or in the building's common areas. (Signature) (Date) Client Name: Case Number: a`E2^.��+d4"�.4 - _ ESG • • Screening 4 f v� z September 2013 An United States Environmental Protection Agency United States Consumer Product Safety Commission �PP�M£N7°F,h0 % United States Department of Housing and Urban Development '9aMr oEVE�° Are You Planning to Buy or Rent a Home Built Before 1978? Did you know that many homes built before 1978 have lead -based paint? Lead from paint, chips, and dust can pose serious health hazards. Read this entire brochure to learn: • How lead gets into the body • About health effects of lead • What you can do to protect your family • Where to go for more information Before renting or buying a pre-1978 home or apartment, federal law requires: • Sellers must disclose known information on lead -based paint or lead - based paint hazards before selling a house. • Real estate sales contracts must include a specific warning statement about lead -based paint. Buyers have up to 10 days to check for lead. • Landlords must disclose known information on lead -based paint and lead -based paint hazards before leases take effect. Leases must include a specific warning statement about lead -based paint. If undertaking renovations, repairs, or painting (RRP) projects in your pre-1978 home or apartment: • Read EPA's pamphlet, The Lead -Safe Certified Guide to Renovate Right, to learn about the lead -safe work practices that contractors are required to follow when working in your home (see page 12). Simple Steps to Protect Your Family from Lead Hazards If you think your home has lead -based paint: • Don't try to remove lead -based paint yourself. • Always keep painted surfaces in good condition to minimize deterioration. • Get your home checked for lead hazards. Find a certified inspector or risk assessor at epa.gov/lead. • Talk to your landlord about fixing surfaces with peeling or chipping paint. • Regularly clean floors, window sills, and other surfaces. • Take precautions to avoid exposure to lead dust when remodeling. • When renovating, repairing, or painting, hire only EPA- or state - approved Lead -Safe certified renovation firms. • Before buying, renting, or renovating your home, have it checked for lead -based paint. • Consult your health care provider about testing your children for lead. Your pediatrician can check for lead with a simple blood test. • Wash children's hands, bottles, pacifiers, and toys often. • Make sure children avoid fatty (or high fat) foods and eat nutritious meals high in iron and calcium. • Remove shoes or wipe soil off shoes before entering your house. Lead Gets into the Body in Many Ways Adults and children can get lead into their bodies if they: • Breathe in lead dust (especially during activities such as renovations, repairs, or painting that disturb painted surfaces). • Swallow lead dust that has settled on food, food preparation surfaces, and other places. • Eat paint chips or soil that contains lead. Lead is especially dangerous to children under the age of 6. • At this age, children's brains and nervous systems are more sensitive to the damaging effects of lead. • Children's growing bodies absorb more lead. • Babies and young children often put their hands and other objects in their mouths. These objects can have lead dust on them. Women of childbearing age should know that lead is dangerous to a developing fetus. • Women with a high lead level in their system before or during pregnancy risk exposing the fetus to lead through the placenta during fetal development. 3 Health Effects of Lead Lead affects the body in many ways. It is important to know that even exposure to low levels of lead can severely harm children. In children, exposure to lead can cause: Brain Nerve Damage Hearing • Nervous system and kidney damage Problems • Learning disabilities, attention deficit disorder, and decreased intelligence Slowed • Speech, language, and behavior problems • Poor muscle coordination • Decreased muscle and bone growth • Hearing damage Digestive Problems While low -lead exposure is most common, Reproductive Problems exposure to high amounts of lead can have (Adults) devastating effects on children, including seizures, unconsciousness, and, in some cases, death. Although children are especially susceptible to lead exposure, lead can be dangerous for adults, too. In adults, exposure to lead can cause: • Harm to a developing fetus • Increased chance of high blood pressure during pregnancy • Fertility problems (in men and women) • High blood pressure • Digestive problems • Nerve disorders • Memory and concentration problems • Muscle and joint pain Check Your Family for Lead Get your children and home tested if you think your home has lead. Chi Idren's blood lead levels tend to increase rapidly from 6 to 12 months of age, and tend to peak at 18 to 24 months of age. Consult your doctor for advice on testing your children. A simple blood test can detect lead. Blood lead tests are usually recommended for; Children at ages 1 and 2 Children or other family members who have been exposed to high levels of lead Children who should be tested under your state or local health screening plan Your doctor can explain what the test results mean and if more testing will be needed. 4 Where Lead -Based Paint Is Found In general, the older your home or childcare facility, the more likely it has lead -based paint.' Many homes, including private, federally -assisted, federally - owned housing, and childcare facilities built before 1978 have lead -based paint. In 1978, the federal government banned consumer uses of lead -containing paint.' Learn how to determine if paint is lead -based paint on page 7. Lead can be found: • In homes and childcare facilities in the city, country, or suburbs, • In private and public single-family homes and apartments, • On surfaces inside and outside of the house, and • In soil around a home. (Soil can pick up lead from exterior paint or other sources, such as past use of leaded gas in cars.) Learn more about where lead is found at epa.gov/lead. ' "Lead -based paint" is currently defined by the federal government as paint with lead levels greater than or equal to 1.0 milligram per square centimeter (mg/cm), or more than 0.5% by weight. ' 'Lead -containing paint"is currently defined by the federal government as lead in new dried paint in excess of 90 parts per million (ppm) by weight. 5 Identifying Lead -Based Paint and Lead -Based Paint Hazards Deteriorating lead -based paint (peeling, chipping, chalking, cracking, or damaged paint) is a hazard and needs immediate attention. Lead -based paint may also be a hazard when found on surfaces that children can chew or that get a lot of wear and tear, such as: • On windows and window sills • Doors and door frames • Stairs, railings, banisters, and porches Lead -based paint is usually not a hazard if it is in good condition and if it is not on an impact or friction surface like a window. Lead dust can form when lead -based paint is scraped, sanded, or heated. Lead dust also forms when painted surfaces containing lead bump or rub together. Lead paint chips and dust can get on surfaces and objects that people touch. Settled lead dust can reenter the air when the home is vacuumed or swept, or when people walk through it. EPA currently defines the following levels of lead in dust as hazardous: • 40 micrograms per square foot (µg/ft2) and higher for floors, including carpeted floors • 250 µg/ft2 and higher for interior window sills Lead in soil can be a hazard when children play in bare soil or when people bring soil into the house on their shoes. EPA currently defines the following levels of lead in soil as hazardous: - 400 parts per million (ppm) and higher in play areas of bare soil • 1,200 ppm (average) and higher in bare soil in the remainder of the yard Remember, lead from paint chips —which you can see —and lead dust —which you may not be able to see —both can be hazards. The only way to find out if paint, dust, or soil lead hazards exist is to test for them. The next page describes how to do this. 6 Checking Your Home for lead You can get your home tested for lead in several different ways: A lead -based paint inspection tells you if your home has lead - based paint and where it is located. It won't tell you whether your home currently has lead hazards. A trained and certified testing professional, called a lead -based paint inspector, will conduct a paint inspection using methods, such as: • Portable x-ray fluorescence (XRF) machine • Lab tests of paint samples • A risk assessment tells you if your home currently has any lead hazards from lead in paint, dust, or soil. It also tells you what actions to take to address any hazards. A trained and certified testing professional, called a risk assessor, will: • Sample paint that is deteriorated on doors, windows, floors, stairs, and walls • Sample dust near painted surfaces and sample bare soil in the yard • Get lab tests of paint, dust, and soil samples • A combination inspection and risk assessment tells you if your home has any lead -based paint and if your home has any lead hazards, and where both are located. Be sure to read the report provided to you after your inspection or risk assessment is completed, and ask questions about anything you do not understand. Checking Your Home for Lead, continued In preparing for renovation, repair, or painting work in a pre-1978 home, Lead -Safe Certified renovators (see page 12) may: • Take paint chip samples to determine if lead -based paint is present in the area planned for renovation and send them to an EPA -recognized lead lab for analysis. In housing receiving federal assistance, the person collecting these samples must be a certified lead -based paint inspector or risk assessor • Use EPA -recognized tests kits to determine if lead -based paint is absent (but not in housing receiving federal assistance) • Presume that lead -based paint is present and use lead -safe work practices There are state and federal programs in place to ensure that testing is done safely, reliably, and effectively. Contact your state or local agency for more information, visit epa.gov/lead, or call 1-800-424-LEAD (5323) for a list of contacts In your area.3 3 Hearing -or speech -challenged individuals may access this number through TTYby calling the Federal Relay Service at 1-800-877-8399. What You Can Do Now to Protect Your Family If you suspect that your house has lead -based paint hazards, you can take some immediate steps to reduce your family's risk: • If you rent, notify your landlord of peeling or chipping paint. • Keep painted surfaces clean and free of dust. Clean floors, window frames, window sills, and other surfaces weekly. Use a mop or sponge with warm water and a general all-purpose cleaner. (Remember: never mix ammonia and bleach products together because they can form a dangerous gas.) • Carefully clean up paint chips immediately without creating dust. • Thoroughly rinse sponges and mop heads often during cleaning of dirty or dusty areas, and again afterward. • Wash your hands and your children's hands often, especially before they eat and before nap time and bed time. • Keep play areas clean. Wash bottles, pacifiers, toys, and stuffed animals regularly. • Keep children from chewing window sills or other painted surfaces, or eating soil. • When renovating, repairing, or painting, hire only EPA- or state - approved Lead -Safe Certified renovation firms (see page 12). • Clean or remove shoes before entering your home to avoid tracking in lead from soil. • Make sure children avoid fatty (or high fat) foods and eat nutritious meals high in iron and calcium. Children with good diets absorb less lead. 9 Reducing Lead Hazards Disturbing lead -based paint or removing lead improperly can increase the hazard to your family by spreading even more lead dust around the house. In addition to day-to-day cleaning and good nutrition, you can temporarily reduce lead -based paint hazards by taking actions, such as repairing damaged painted surfaces and planting grass to cover lead - contaminated soil. These actions are not permanent solutions and will need ongoing attention. • You can minimize exposure to lead when renovating, repairing, or painting by hiring an EPA- or state - certified renovator who is trained in the use of read -safe work practices. If you are a do-it-yourselfer, learn how to use lead -safe work practices in your home. • To remove lead hazards permanently, you should hire a certified lead abatement contractor. Abatement (or permanent hazard elimination) methods include removing, sealing, or enclosing lead -based paint with special materials. lust painting over the hazard with regular paint is not permanent control. Always use a certified contractor who is trained to address lead hazards safely. • Hire a Lead -Safe Certified firm (see page 12) to perform renovation, repair, or painting (RRP) projects that disturb painted surfaces. • To correct lead hazards permanently, hire a certified lead abatement professional. This will ensure your contractor knows how to work safely and has the proper equipment to clean up thoroughly. Certified contractors will employ qualified workers and follow strict safety rules as set by their state or by the federal government. 10 Reducing Lead Hazards, continued If your home has had dead abatement work done or if the housing is receiving federal assistance, once the work is completed, dust cleanup activities must be conducted until clearance testing indicates that lead dust levels are below the following levels: • 40 micrograms per square foot (µg/ft') for floors, including carpeted floors • 250 µg/ft' for interior windows sills • 400 µg/ft' for window troughs For help in locating certified lead abatement professionals in your area, call your state or local agency (see pages 14 and 15), or visit epa.gov/lead, or call 1-800-424-LEAD. Renovating, Remodeling, or Repairing (RRP) a Home with Lead -Based Paint If you hire a contractor to conduct renovation, repair, or painting (RRP) projects in your pre-1978 home or childcare facility (such as pre-school and kindergarten), your contractor must: • Be a Lead -Safe Certified firm approved by EPA or an EPA -authorized state program • Use qualified trained individuals (Lead -Safe) Certified renovators) who follow specific lead -safe work practices to prevent lead contamination • Provide a copy of EPA's lead hazard information document, The Lead -Safe Certified Guide to,=v Renovate Right RRP contractors working in pre-1978 homes and childcare facilities must follow lead -safe work practices that: • Contain the work area. The area must be contained so that dust and debris do not escape from the work area. Warning signs must be put up, and plastic or other impermeable material and tape must be used. • Avoid renovation methods that generate large amounts of lead -contaminated dust. Some methods generate so much lead - contaminated dust that their use is prohibited, They are: • Open -flame burning or torching • Sanding, grinding, planing, needle gunning, or blasting with power tools and equipment not equipped with a shroud and HEPA vacuum attachment and • Using a heat gun at temperatures greater than 1100°F • Clean up thoroughly. The work area should be cleaned up daily. When all the work is done, the area must be cleaned up using special cleaning methods. • Dispose of waste properly. Collect and seal waste in a heavy duty bag or sheeting. When transported, ensure that waste is contained to prevent release of dust and debris. To learn more about EPA's requirements for RRP projects visit epa.gov/getleadsafe, or read The Lead -Safe Certified Guide to 12 Renovate Right. Other Sources of Lead While paint, dust, and soil are the most common sources of lead, other lead sources also exist: • Drinking water. Your home might have plumbing with lead or lead solder. You cannot see, smell, or taste lead, and boiling your water will not get rid of lead. If you think your plumbing might contain lead: • Use only cold water for drinking and cooking. • Run water for 15 to 30 seconds before drinking it, especially if you have not used your water for a few hours. Call your local health department or water supplier to find out about testing your water, or visit epa.gov/lead for EPA's lead in drinking water information. • Lead smelters or other industries that release lead into the air, • Your job. If you work with lead, you could bring it home on your body or clothes. Shower and change clothes before coming home. Launder your work clothes separately from the rest of your family's clothes. • Hobbies that use lead, such as making pottery or stained glass, or refinishing furniture. Call your local health department for information about hobbies that may use lead. • Old toys and furniture may have been painted with lead -containing paint. Older toys and other children's products may have parts that contain lead.4 • Food and liquids cooked or stored in lead crystal or lead -glazed pottery or porcelain may contain lead. • Folk remedies, such as "greta" and "azarcon," used to treat an upset stomach. ^ In 1978, the federal government banned toys, other children's products, and furniture with lead -containing paint (16 CFR 1303). In 2008, the federal government banned lead in most children's products.The federal government currently bans lead in excess of 100 ppm by weight in most children's products (76 FR 44463). 13 For More Information The National Lead Information Center Learn how to protect children from lead poisoning and get other information about lead hazards on the Web at epa.gov/lead and hud.gov/lead, or call 1-800-424-LEAD (5323). EPA's Safe Drinking Water Hotline For information about lead in drinking water, call 1-800-426-4791, or visit epa.gov/lead for information about lead in drinking water. Consumer Product Safety Commission (CPSC) Hotline For information on lead in toys and other consumer products, or to report an unsafe consumer product or a product -related injury, call 1-800-638-2772, or visit CPSC's website at cpsc.gov or saferproducts.g ov. State and Local Health and Environmental Agencies Some states, tribes, and cities have their own rules related to lead - based paint. Check with your local agency to see which laws apply to you. Most agencies can also provide information on finding a lead abatement firm in your area, and on possible sources of financial aid for reducing lead hazards. Receive up-to-date address and phone information for your state or local contacts on the Web at epa.gov/lead, or contact the National Lead Information Center at 1-800-424-LEAD. Hearing- or speech -challenged individuals may access any of the phone numbers in this brochure through TTY by calling the toll - free Federal Relay Service at 1-800-877-8339. 14 U. S. Environmental Protection Agency (EPA) Regional Offices The mission of EPA is to protect human health and the environment. Your Regional EPA Office can provide further information regarding regulations and lead protection programs. Region 7 (Connecticut, Massachusetts, Maine, Region 6 (Arkansas, Louisiana, New Mexico, New Hampshire, Rhode Island, Vermont) Oklahoma, Texas, and 66 Tribes) Regional Lead Contact U.S. EPA Region 1 5 Post Office Square, Suite 100, OES 05-4 Boston, MA 02109-3912 (888) 372-7341 Region 2 (New Jersey, New York, Puerto Rico, Virgin Islands) Regional Lead Contact U.S. EPA Region 2 2890 Woodbridge Avenue Building 205, Mail Stop 225 Edison, NJ M37-3679 (732) 321-6671 Region 3 (Delaware, Maryland, Pennsylvania, Virginia, DC, West Virginia) Regional Lead Contact U.S. EPA Region 3 1650 Arch Street Philadelphia, PA 19103 (215) 874-2088 Region 4 (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee) Regional Lead Contact U.S. EPA Region 4 AFCTower, 12th Floor, Air, Pesticides &Toxics 61 Forsyth Street, SW Atlanta, GA 30303 (404) 562-8998 Region 5 (Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin) Regional Lead Contact U.S. EPA Region 5 (DT-8J) 77 West Jackson Boulevard Chicago, IL 60604-3666 (312) 886-7836 15 Regional Lead Contac: U.S. EPA Region 6 1445 Ross Avenue, 12th Floor Dallas,TX 75202.2733 (214) 665-2704 Region 7 (Iowa, Kansas, Missouri, Nebraska) Regional Lead Contact U.S. EPA Region 7 11201 Renner Blvd. WWPD/TOPE Lenexa, KS 66219 (800) 223-0425 Region 8 (Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming) Regional Lead Contact U.S. EPA Region 8 1595 Wynkoop St. Denver, CO 80202 (303) 312-6966 Region 9 (Arizona, California, Hawaii, Nevada) Regional Lead Contact U.S. EPA Region 9 (CMD-4-2) 75 Hawthorne Street San Francisco, CA 94105 (415) 947-4280 Region 10 (Alaska, Idaho, Oregon, Washington) Regional Lead Contact U.S. EPA Region 10 Solid Waste &Toxics Unit (WCM-128) 1200 Sixth Avenue, Suite 900 Seattle, WA 98101 (206) S53-1200 Consumer Product Safety Commission (CPSC] The CPSC protects the public against unreasonable risk of injury from consumer products through education, safety standards activities, and enforcement. Contact CPSC for further information regarding consumer product safety and regulations. CPSC 4330 East West H ig hway Bethesda, MD 20814-4421 1-800-638-2772 cpsc.gov or saferproducts.gov U. S. Department of Housing and Urban Development (HUD) HUD's mission is to create strong, sustainable, inclusive communities and quality affordable homes for all. Contact HUD's Office of Healthy Homes and Lead Hazard Control for further information regarding the Lead Safe Housing Rule, which protects families in pre-1978 assisted housing, and for the lead hazard control and research grant programs. HUD 451 Seventh Street, SW, Room 8236 Washington, DC 20410-3000 (202) 402-7698 hud.gov/offices/lead/ This document is in the public domain. It may be produced by an individual or organization without permission. Information provided in this booklet is based upon current scientific and technical understanding of the issues presented and is reflective of the jurisdiction, al boundaries established by the statutes governing the co-authoring agencies. Following the advice given will not necessarily provide complete protection in all situations or against all health hazards that can be caused by lead exposure. U.S.EFA Washington DC 20460 EPA-747-K-12-001 U. S. CPSC Bethesda MD 20814 September 2013 U. S. HUD Washington DC 20410 16 Lead From Paint, Dust, and Soil in and Around Your Home Can Be Dangerous if Not Managed Properly • Children under 6 years old are most at risk for lead poisoning in your home. • Lead exposure can harm young children and babies even before they are born. • Homes, schools, and child care facilities built before 1978 are likely to contain lead -based paint. • Even children who seem healthy may have dangerous levels of lead in their bodies. • Disturbing surfaces with lead -based paint or removing lead -based paint improperly can increase the danger to your family. People can get lead into their bodies by breathing or swallowing lead dust, or by eating soil or paint chips containing lead. • People have many options for reducing lead hazards. Generally, lead -based paint that is in good condition is not a hazard (see page 10). Families Forward Exhibit F •:- TBRA Program Budget — Families Forward Huntington Beach, California 2018/19 2019/20* HOME Funds TBRA & Security Deposits', $ 200,000 $ 220,000 HQS InspectionS2,3 37,500 38,625 Income Eligibility4 12,500 12,875 Total HOME Funds 250,000 271,500 City Inclusionary5 45,000 46,350 Total City Contract 295,000 317,850 Families Forward Match' 29,500 30,385 Total Budget $ 324,500 S 348,235 ' Approximately 15 Eligible Households can receive assistance for 6 to 12 months per year. Z Eligible Household and households may need more than one inspection before move in. Assumes 30 inspections at $500. Inspections will include Housing Quality Inspections including Habitability Standards Checklist, Lead Screening Worksheet, and Rent Reasonableness analysis. 3After move in, assumes inspections at $250 per inspections. Inspections include lease compliance and unit inspection. Assumes monthly inspection for up to 6 months. 4Assumes 25 Screenings per year at $500 per screening. Assumes Income Eligibility every 6 months for each adult with income. Income Eligibility includes assessment and verification of income including employment earnings, unemployment, alimony, child support, or other benefits received. ' Includes ineligible administrative costs under the HOME program, such as case management, housing navigation, supportive services, supervision, and overhead. ' Includes ineligible administrative costs under the HOME program, such as case management, housing navigation, supportive services, supervision, and overhead. *FY 2019/20 assumes 10% increase in rent and 3% increase in cost of living. FAMIFOR-01 AGARCIA ,�coR�►" CERTIFICATE OF LIABILITY INSURANCE �.� DATEiMM/DD/YYYY) 08/24/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License # OM10410 CONTACT NAME: PHONE , Ext): (949 381-7700 FAX 949 487-6151 ) (AIC, No):( ) Armstrong/Robitaille/Riegle Business and Insurance Solutions 830 Roosevelt, Suite 200 Irvine, CA 92620 ADDRIESS: info@ar-ins.com INSURERS AFFORDING COVERAGE NAIC # INSURER A: Philadelphia Indemnity Ins Co 18058 INSURED INSURER B : New York Marine and General Ins Co 16608 INSURER C : Families Forward INSURER D : 8 Thomas Irvine, CA 92618 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTRI TYPE OF INSURANCE ADDL SUBR D POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR X PHPK1843361 07/01/2018 07/01/2019 DAMAGE TO RENTED PREMISES Ea occunence 100,000 S ME EXP (Any oneperson) S 20,000 PERSDNAL&ADV INJURY S 1,000,000 AGGREGATE LIMIT APPLIES PER POLICY ❑ PECOT- El LOC GENERAL AGGREGATE $ 3,000,000 GEN'L PRODUCTS - COMP/OP AGG $ 3,000,000 SEXUAL ABUSE $ 1,000,000 OTHER A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 $ BODILY INJURY Perperson) $ ANY AUTO PHPK1843361 07/01/2018 07/01/2019 OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY Per accident $ perr accidentDAMAGE $ X AUTOS ONLY X AUUTOS ONLY $ A UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 X AGGREGATE $ 4,000,000 EXCESS LIAB CLAIMS -MADE PHUB636160 07/01/2018 07/01/2019 DED I X RETENTION $ 10,000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/M EMBER EXCLUDED? )Mandatoryin NH) N / A WC201800006303 07/01/2018 07/01/2019 X PER OTH- STATUTE ER EL EACH ACCIDENT 1,000,000 $ EL DISEASE - EA EMPLOYEE $ 1,000,000 If yes, descnbe under DESCRIPTION OF OPERATIONS below EL DISEASE -POLICY LIMIT 1 QQQ QQQ $ A Sexual Misconduct PHPK1843361 07/01/2018 07/01/2019 lOccurrence 1,000,000 A Prof. Errors & Omiss PHPK1843361 07/01/2018 07/01/2019 Occurrence 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD '101, Additional Remarks Schedule, may be attached if more space is required) The City of Huntington Beach, its officials, agents, employees, representative and volunteers are named as additional insured on the General Liability per attached form, as required by written contract Primary and Non -Contributory applies to the General Liability per attached form. APPROVED AS TO FORM By: MICHAEL E. GATES cm ATTORNEY CERTIFICATE HOLDER CANCELLATION CITY OF HUNTINGTON BEACH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City of Huntington Beach tY g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 2000 Main Street Huntington Beach, CA 92648 AUTHORIZED REPRESENTATIVE m 9a rA J ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy #PHPK1843361 PI-GLD-HS (10/11) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL LIABILITY DELUXE ENDORSEMENT: HUMAN SERVICES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE It is understood and agreed that the following extensions only apply in the event that no other specific coverage for the indicated loss exposure is provided under this policy. If such specific coverage applies, the terms, conditions and limits of that coverage are the sole and exclusive coverage applicable under this policy, unless otherwise noted on this endorsement. The following is a summary of the Limits of Insurance and additional coverages provided by this endorsement. For complete details on specific coverages, consult the policy contract wording. Coverage Applicable Limit of Insurance Page # Extended Property Damage Included 2 Limited Rental Lease Agreement Contractual Liability $50,000 limit 2 Non -Owned Watercraft Less than 58 feet 2 Damage to Property You Own, Rent, or Occupy $30,000 limit 2 Damage to Premises Rented to You $1,000,000 3 HIPAA Clarification 4 Medical Payments $20,000 5 Medical Payments — Extended Reporting Period 3 years 5 Athletic Activities Amended 5 Supplementary Payments— Bail Bonds $5,000 5 Supplementary Payment — Loss of Earnings $1,000 per day 5 Employee Indemnification Defense Coverage $25,000 5 Key and Lock Replacement — Janitorial Services Client Coverage $10,000 limit 6 Additional Insured — Newly Acquired Time Period Amended 6 Additional Insured — Medical Directors and Administrators Included 7 Additional Insured — Managers and Supervisors (with Fellow Employee Coverage) Included 7 Additional Insured — Broadened Named Insured Included 7 Additional Insured — Funding Source Included 7 Additional Insured — Home Care Providers Included 7 Additional Insured — Managers, Landlords, or Lessors of Premises Included 7 Additional Insured — Lessor of Leased Equipment Included 7 Additional Insured — Grantor of Permits Included 8 Additional Insured — Vendor Included 8 Additional Insured — Franchisor Included 9 Additional Insured — When Required by Contract Included 9 Additional Insured — Owners, Lessees, or Contractors Included 9 Additional Insured — State or Political Subdivisions Included 10 Page 1 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) Duties in the Event of Occurrence, Claim or Suit Included 10 Unintentional Failure to Disclose Hazards Included 10 Transfer of Rights of Recovery Against Others To Us Clarification 10 Liberalization Included 11 Bodily Injury — includes Mental Anguish Included 11 Personal and Advertising Injury — includes Abuse of Process, Discrimination Included 11 A. Extended Property Damage SECTION I — COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Subsection 2. Exclusions, Paragraph a. is deleted in its entirety and replaced by the following: a. Expected or Intended Injury "Bodily injury" or property damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" or "property damage" resulting from the use of reasonable force to protect persons or property. B. Limited Rental Lease Agreement Contractual Liability SECTION I — COVERAGES, COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Subsection 2. Exclusions, Paragraph b. Contractual Liability is amended to include the following: (3) Based on the named insured's request at the time of claim, we agree to indemnify the named insured for their liability assumed in a contract or agreement regarding the rental or lease of a premises on behalf of their client, up to $50,000_ This coverage extension only applies to rental lease agreements. This coverage is excess over any renter's liability insurance of the client. C. Non -Owned Watercraft SECTION I — COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Subsection 2. Exclusions, Paragraph g. (2) is deleted in its entirety and replaced by the following: (2) A watercraft you do not own that is: (a) Less than 58 feet long; and (b) Not being used to carry persons or property for a charge; This provision applies to any person, who with your consent, either uses or is responsible for the use of a watercraft. This insurance is excess over any other valid and collectible insurance available to the insured whether primary, excess or contingent. D. Damage to Property You Own, Rent or Occupy SECTION I — COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE Page 2 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) LIABILITY, Subsection 2. Exclusions, Paragraph j. Damage to Property, Item (1) is deleted in its entirety and replaced with the following: (1) Property you own, rent, or occupy, including any costs or expenses incurred by you, or any other person, organization or entity, for repair, replacement, enhancement, restoration or maintenance of such property for any reason, including prevention of injury to a person or damage to another's property, unless the damage to property is caused by your client, up to a $30,000 limit. A client is defined as a person under your direct care and supervision. E. Damage to Premises Rented to You 1. If damage by fire to premises rented to you is not otherwise excluded from this Coverage Part, the word "fire" is changed to "fire, lightning, explosion, smoke, or leakage from automatic fire protective systems" where it appears in: a. The last paragraph of SECTION I —COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Subsection 2. Exclusions; is deleted in its entirety and replaced by the following: Exclusions c. through n. do not apply to damage by fire, lightning, explosion, smoke, or leakage from automatic fire protective systems to premises while rented to you or temporarily occupied by you with permission of the owner. A separate limit of insurance applies to this coverage as described in SECTION III — LIMITS OF INSURANCE. b. SECTION III — LIMITS OF INSURANCE, Paragraph 6. is deleted in its entirety and replaced by the following: Subject to Paragraph 5. above, the Damage To Premises Rented To You Limit is the most we will pay under Coverage A for damages because of "property damage" to any one premises, while rented to you, or in the case of damage by fire, lightning, explosion, smoke, or leakage from automatic fire protective systems while rented to you or temporarily occupied by you with permission of the owner. c. SECTION V — DEFINITIONS, Paragraph 9.a., is deleted in its entirety and replaced by the following: A contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire, lightning, explosion, smoke, or leakage from automatic fire protective systems to premises while rented to you or temporarily occupied by you with permission of the owner is not an "insured contract-, 2. SECTION IV— COMMERCIAL GENERAL LIABILITY CONDITIONS, Subsection 4. Other Insurance, Paragraph b. Excess Insurance, (1) (a) (ii) is deleted in its entirety and replaced by the following: That is insurance for fire, lightning, explosion, smoke, or leakage from automatic fire protective systems for premises rented to you or temporarily occupied by you with permission of the owner; 3. The Damage To Premises Rented To You Limit section of the Declarations is amended to the greater of: Page 3 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) a. $1,000,000; or b. The amount shown in the Declarations as the Damage to Premises Rented to You Limit. This is the most we will pay for all damage proximately caused by the same event, whether such damage results from fire, lightning, explosion, smoke, or leaks from automatic fire protective systems or any combination thereof. F. HIPAA SECTION I — COVERAGES, COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY, is amended as follows: 1. Paragraph 1. Insuring Agreement is amended to include the following: We will pay those sums that the insured becomes legally obligated to pay as damages because of a "violation(s)" of the Health Insurance Portability and Accountability Act (HIPAA). We have the right and the duty to defend the insured against any "suit," "investigation," or "civil proceeding" seeking these damages. However, we will have no duty to defend the insured against any "suit" seeking damages, "investigation," or "civil proceeding" to which this insurance does not apply. 2. Paragraph 2. Exclusions is amended to include the following additional exclusions: This insurance does not apply to: a. Intentional, Willful, or Deliberate Violations Any willful, intentional, or deliberate "violation(s)" by any insured. b. Criminal Acts Any "violation" which results in any criminal penalties under the HIPAA. c. Other Remedies Any remedy other than monetary damages for penalties assessed. d. Compliance Reviews or Audits Any compliance reviews by the Department of Health and Human Services. 3. SECTION V — DEFINITIONS is amended to include the following additional definitions: a. "Civil proceeding" means an action by the Department of Health and Human Services (HHS) arising out of "violations." b. "Investigation" means an examination of an actual or alleged "violation(s)" by HHS. However, "investigation" does not include a Compliance Review. c. "Violation" means the actual or alleged failure to comply with the regulations included in the HIPAA. Page 4 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) G. Medical Payments — Limit Increased to $20,000, Extended Reporting Period If COVERAGE C MEDICAL PAYMENTS is not otherwise excluded from this Coverage Part: 1. The Medical Expense Limit is changed subject to all of the terms of SECTION III - LIMITS OF INSURANCE to the greater of: a. $20,000; or b. The Medical Expense Limit shown in the Declarations of this Coverage Part. 2. SECTION I — COVERAGE, COVERAGE C MEDICAL PAYMENTS, Subsection 1. Insuring Agreement, a. (3) (b) is deleted in its entirety and replaced by the following: (b) The expenses are incurred and reported to us within three years of the date of the accident. H. Athletic Activities SECTION I — COVERAGES, COVERAGE C MEDICAL PAYMENTS, Subsection 2. Exclusions, Paragraph e. Athletic Activities is deleted in its entirety and replaced with the following: e. Athletic Activities To a person injured while taking part in athletics. 1. Supplementary Payments SECTION I — COVERAGES, SUPPLEMENTARY PAYMENTS - COVERAGE A AND B are amended as follows: 1. b. is deleted in its entirety and replaced by the following: 1. b. Up to $5000 for cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these. 1.d. is deleted in its entirety and replaced by the following: 1. d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit", including actual loss of earnings up to $1,000 a day because of time off from work. J. Employee Indemnification Defense Coverage SECTION I — COVERAGES, SUPPLEMENTARY PAYMENTS — COVERAGES A AND B the following is added: We will pay, on your behalf, defense costs incurred by an "employee" in a criminal proceeding occurring in the course of employment. The most we will pay for any "employee" who is alleged to be directly involved in a criminal proceeding is $25,000 regardless of the numbers of "employees," claims or "suits" brought or persons or organizations making claims or bringing "suits. Page 5 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) K. Key and Lock Replacement — Janitorial Services Client Coverage SECTION I — COVERAGES, SUPPLEMENTARY PAYMENTS — COVERAGES A AND B is amended to include the following: We will pay for the cost to replace keys and locks at the "clients" premises due to theft or other loss to keys entrusted to you by your "client," up to a $10,000 limit per occurrence and $10,000 policy aggregate. We will not pay for loss or damage resulting from theft or any other dishonest or criminal act that you or any of your partners, members, officers, "employees", "managers", directors, trustees, authorized representatives or any one to whom you entrust the keys of a "client" for any purpose commit, whether acting alone or in collusion with other persons. The following, when used on this coverage, are defined as follows: a. "Client' means an individual, company or organization with whom you have a written contract or work order for your services for a described premises and have billed for your services. b. "Employee" means (1) Any natural person: (a) While in your service or for 30 days after termination of service; (b) Who you compensate directly by salary, wages or commissions; and (c) Who you have the right to direct and control while performing services for you; or (2) Any natural person who is furnished temporarily to you: (a) To substitute for a permanent "employee" as defined in Paragraph (1) above, who is on leave; or (b) To meet seasonal or short-term workload conditions; while that person is subject to your direction and control and performing services for you. (3) "Employee" does not mean: (a) Any agent, broker, person leased to you by a labor leasing firm, factor, commission merchant, consignee, independent contractor or representative of the same general character: or (b) Any "manager," director or trustee except while performing acts coming within the scope of the usual duties of an "employee." c. "Manager" means a person serving in a directorial capacity for a limited liability company. L. Additional Insureds SECTION II — WHO IS AN INSURED is amended as follows: 1. If coverage for newly acquired or formed organizations is not otherwise excluded from this Page 6 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) Coverage Part, Paragraph 3.a. is deleted in its entirely and replaced by the following: a. Coverage under this provision is afforded until the end of the policy period. 2. Each of the following is also an insured: a. Medical Directors and Administrators — Your medical directors and administrators, but only while acting within the scope of and during the course of their duties as such. Such duties do not include the furnishing or failure to furnish professional services of any physician or psychiatrist in the treatment of a patient. b. Managers and Supervisors — Your managers and supervisors are also insureds, but only with respect to their duties as your managers and supervisors. Managers and supervisors who are your "employees" are also insureds for "bodily injury" to a co - "employee" while in the course of his or her employment by you or performing duties related to the conduct of your business. This provision does not change Item 2.a.(1)(a) as it applies to managers of a limited liability company. c. Broadened Named Insured — Any organization and subsidiary thereof which you control and actively manage on the effective date of this Coverage Part. However, coverage does not apply to any organization or subsidiary not named in the Declarations as Named Insured, if they are also insured under another similar policy, but for its termination or the exhaustion of its limits of insurance. d. Funding Source — Any person or organization with respect to their liability arising out of: (1) Their financial control of you; or (2) Premises they own, maintain or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. e. Home Care Providers — At the first Named Insured's option, any person or organization under your direct supervision and control while providing for you private home respite or foster home care for the developmentally disabled. f. Managers, Landlords, or Lessors of Premises — Any person or organization with respect to their liability arising out of the ownership, maintenance or use of that part of the premises leased or rented to you subject to the following additional exclusions: This insurance does not apply to: (1) Any "occurrence" which takes place after you cease to be a tenant in that premises; or (2) Structural alterations, new construction or demolition operations performed by or on behalf of that person or organization. g. Lessor of Leased Equipment — Automatic Status When Required in Lease Agreement With You — Any person or organization from whom you lease equipment when you and such person or organization have agreed in writing in a contract or agreement that such person or organization is to be added as an additional insured on your policy. Such person or Page 7 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) organization is an insured only with respect to liability for "bodily injury," "property damage" or "personal and advertising injury' caused, in whole or in part, by your maintenance, operation or use of equipment leased to you by such person or organization. A person's or organization's status as an additional insured under this endorsement ends when their contract or agreement with you for such leased equipment ends. With respect to the insurance afforded to these additional insureds, this insurance does not apply to any "occurrence" which takes place after the equipment lease expires. h. Grantors of Permits — Any state or political subdivision granting you a permit in connection with your premises subject to the following additional provision: (1) This insurance applies only with respect to the following hazards for which the state or political subdivision has issued a permit in connection with the premises you own, rent or control and to which this insurance applies: (a) The existence, maintenance, repair, construction, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners or decorations and similar exposures; (b) The construction, erection, or removal of elevators; or (c) The ownership, maintenance, or use of any elevators covered by this insurance. i. Vendors — Only with respect to "bodily injury" or "property damage" arising out of "your products" which are distributed or sold in the regular course of the vendor's business, subject to the following additional exclusions: (1) The insurance afforded the vendor does not apply to: (a) "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; (b) Any express warranty unauthorized by you; (c) Any physical or chemical change in the product made intentionally by the vendor; (d) Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container, (e) Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products; (f) Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; Page 8 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) (g) Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor; or (h) "Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does not apply to: (i) The exceptions contained in Sub -paragraphs (d) or (f); or (ii) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products. (2) This insurance does not apply to any insured person or organization, from whom you have acquired such products, or any ingredient, part or container, entering into, accompanying or containing. j. Franchisor — Any person or organization with respect to their liability as the grantor of a franchise to you. k. As Required by Contract — Any person or organization where required by a written contract executed prior to the occurrence of a loss. Such person or organization is an additional insured for "bodily injury," "property damage" or "personal and advertising injury" but only for liability arising out of the negligence of the named insured. The limits of insurance applicable to these additional insureds are the lesser of the policy limits or those limits specified in a contract or agreement. These limits are included within and not in addition to the limits of insurance shown in the Declarations I. Owners, Lessees or Contractors — Any person or organization, but only with respect to liability for "bodily injury," "property damage" or "personal and advertising injury" caused, in whole or in part, by: (1) Your acts or omissions; or (2) The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured when required by a contract. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: (a) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or (b) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. Page 9of12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) m. State or Political Subdivisions — Any state or political subdivision as required, subject to the following provisions: (1) This insurance applies only with respect to operations performed by you or on your behalf for which the state or political subdivision has issued a permit, and is required by contract. (2) This insurance does not apply to: (a) 'Bodily injury," "property damage" or "personal and advertising injury' arising out of operations performed for the state or municipality; or (b) "Bodily injury" or "property damage" included within the "products -completed operations hazard." M. Duties in the Event of Occurrence, Claim or Suit SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, Paragraph 2. is amended as follows: a. is amended to include: This condition applies only when the "occurrence" or offense is known to: (1) You, if you are an individual; (2) A partner, if you are a partnership; or (3) An executive officer or insurance manager, if you are a corporation. b. is amended to include: This condition will not be considered breached unless the breach occurs after such claim or "suit" is known to: (1) You, if you are an individual; (2) A partner, if you are a partnership; or (3) An executive officer or insurance manager, if you are a corporation. N. Unintentional Failure To Disclose Hazards SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 6. Representations is amended to include the following: It is agreed that, based on our reliance on your representations as to existing hazards, if you should unintentionally fail to disclose all such hazards prior to the beginning of the policy period of this Coverage Part, we shall not deny coverage under this Coverage Part because of such failure. O. Transfer of Rights of Recovery Against Others To Us SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 8. Transfer of Rights of Page 10 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) Recovery Against Others To Us is deleted in its entirety and replaced by the following: If the insured has rights to recover all or part of any payment we have made under this Coverage Part, those rights are transferred to us. The insured must do nothing after loss to impair them. At our request, the insured will bring "suit" or transfer those rights to us and help us enforce them. Therefore, the insured can waive the insurer's rights of recovery prior to the occurrence of a loss, provided the waiver is made in a written contract. P. Liberalization SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, is amended to include the following: If we revise this endorsement to provide more coverage without additional premium charge, we will automatically provide the additional coverage to all endorsement holders as of the day the revision is effective in your state. Q. Bodily Injury — Mental Anguish SECTION V — DEFINITIONS, Paragraph 3. Is deleted in its entirety and replaced by the following: "Bodily injury" means: a. Bodily injury, sickness or disease sustained by a person, and includes mental anguish resulting from any of these; and b. Except for mental anguish, includes death resulting from the foregoing (Item a. above) at any time. R. Personal and Advertising Injury — Abuse of Process, Discrimination If COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY COVERAGE is not otherwise excluded from this Coverage Part, the definition of "personal and advertising injury" is amended as follows: 1. SECTION V — DEFINITIONS, Paragraph 14.b. is deleted in its entirety and replaced by the following: b. Malicious prosecution or abuse of process; 2. SECTION V — DEFINITIONS, Paragraph 14. is amended by adding the following: Discrimination based on race, color, religion, sex, age or national origin, except when: a. Done intentionally by or at the direction of, or with the knowledge or consent of: (1) Any insured; or (2) Any executive officer, director, stockholder, partner or member of the insured, b. Directly or indirectly related to the employment, former or prospective employment, termination of employment, or application for employment of any person or persons by an insured; Page 11 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. O 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) c. Directly or indirectly related to the sale, rental, lease or sublease or prospective sales, rental, lease or sub -lease of any room, dwelling or premises by or at the direction of any insured; or d. Insurance for such discrimination is prohibited by or held in violation of law, public policy, legislation, court decision or administrative ruling. The above does not apply to fines or penalties imposed because of discrimination. Page 12of12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 9 2011 Philadelphia Indemnity Insurance Company Policy Number: PHPK1843361 PI-GL-005 (07/12) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED PRIMARY AND NON-CONTRIBUTORY INSURANCE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization (Additional Insured): Effective Date: 711118 SECTION II — WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the endorsement Schedule, but only with respect to liability for "bodily injury," "property damage" or "personal and advertising injury" arising out of or relating to your negligence in the performance of "your work" for such person(s) or organization(s) that occurs on or after the effective date shown in the endorsement Schedule. This insurance is primary to and non-contributory with any other insurance maintained by the person or organization (Additional Insured), except for loss resulting from the sole negligence of that person or organization. This condition applies even if other valid and collectible insurance is available to the Additional Insured for a loss or "occurrence" we cover for this Additional Insured. The Additional Insured's limits of insurance do not increase our limits of insurance, as described in SECTION III — LIMITS OF INSURANCE. All other terms, conditions, and exclusions under the policy are applicable to this endorsement and remain unchanged. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. DECLARATION OF HOMELESSNESS STATUS Applicant Name: ❑ I certify, under penalty of perjury, that following information is true and complete: Applicant Signature: Date: *T=Third Party / O=Observation / S=Self-certification Attach Third Party verification documentation and Intake Observation statements behind this form Verification Type T/O/S*/Notes Situation 1 ❑ An individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning Check one of the following ❑ An individual or family with a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus or train station, airport, or camping ground. (T-not required for emergency shelter or street outreach) ❑ An individual or family living in a supervised publicly or privately operated shelter designated to provide temporary living arrangements (including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state, or local government programs for low-income individuals An individual who is exiting an institution where he or she resided for 90 days or less AND who resided in an emergency shelter or place not meant for human habitation immediately before entering that institution. (O-not allowed) Verification Type T/O/S*/Notes Situation 2 ❑ An individual or family who will imminently lose their primary nighttime residence, provided that: The primary nighttime residence will be lost within 14 days of the date of application for homeless assistance AND No subsequent residence has been identified AND The individual or family lacks the resources or support networks, e.g., family, friends, faith -based or other social networks, needed to obtain other permanent housing Verification Type T/O/S*/Notes Situation 3 ❑ Unaccompanied youth under 25 years of age, or families with children and youth, who do not otherwise qualify as homeless under this definition, but who qualifies as "homeless" under another federal statute AND Only T is allowed) have not had a lease, ownership interest, or occupancy agreement in permanent housing at any time during the 60 days immediately preceding the date of application for homeless assistance AND (O is not allowed) have experienced persistent instability as measured by two moves or more during the 60-day period immediately preceding the date of applying for homeless assistance AND (O is not allowed) can be expected to continue in such status for an extended period of time because of chronic disabilities, chronic physical health or mental health conditions, substance addiction, histories of domestic violence or childhood abuse (including neglect), the presence of a child or youth with a disability, OR two or more barriers to employment, which include the lack of a high school degree or General Education Development (GED), illiteracy, low English proficiency, a history of incarceration or detention for criminal activity, and a history of unstable employment; (S is not allowed O is not allowed for barriers to employment) Safety should never be put at risk in order to obtain documentation under this situation. If the provider is a DV Verification Type provider self -certification sufficient. For non -DV providers, if there is no threat of safety supporting verification T/O/S*/Notes should be provided. Situation 4- ❑ Any individual or family who Is fleeing, or is attempting to flee, domestic violence, dating violence, sexual assault, stalking, or other dangerous or life -threatening conditions that relate to violence against the individual or a family member, including a child, that has either taken place within the individual's or family's primary nighttime residence or has made the individual or family afraid to return to their primary nighttime residence AND has no other residence AND lacks the resources or support networks, e.g., family, friends, faith -based or other social networks, to obtain other permanent housing Monthly Budget Net Income: Employment Other: Food Stamps Total: Expenses: Rent Gas Electric Cable Phone Food Car Insurance Gasoline Medical Recreation Savings Hygiene Other: Total: Notes: I have read the duties of a client for the TBRA program and certify that I will comply and adhere to this budget that has been set. Resident's Name - Please Print Resident's Signature Other Household Member Member's Signature Date Date FAMILIES FORWARD Name: The following people live with me: Month/Year: Name (Jnclude Nead o,� 045e ofd Age ,How the person 1s oiteherson's gross and Pays, same of the related to me? (ez5oti.` net rrionthlyincome'. ` household expenses? a• 0 Yes O No b. I I 0 Yes 0 No C. O Yes O No Payable to que Date' Amount What check did this expense cokne.atat of? Rent Gas Electricity Car Payment Transportation (gas, bus) Car Insurance Cell Phone Child Care Installment # 1 Installment # 2 Installment # 3 Other Total: Do not write below this line- To be completed with program staff How much spending money do you have? -, `Paycheck Date ,<,.. ...y`2Wt eh atk+ av�. =. ..:. :...., kdM.i' Paycheck Amount Bills Paid -Spending MoneyAft ending Money Week 1: Week 2: Week 3: Week 4: — Saving for rent Rent amount _ # of checks = amount saved per pay check for rent: